ROSENTHAL REPORT - JUNE 2020

Rosenthal Reports

The death toll from the corona virus recently surpassing 100,000 marks a grim milestone, as states grapple with reopening the country while protecting the public from further spread of the pandemic. In the shadow of this tragedy is another deadly epidemic that must be addressed—the opioid crisis that has killed more than 400,000 Americans over the past two decades. In this edition of the Rosenthal Report, we look at major issues surrounding the opioid crisis and the pandemic.

“Deaths of Despair” Expected to Rise

Drug overdoses and fatalities are increasing in many regions of the country, as those struggling with substance abuse during the pandemic face the challenges of sheltering in place and obtaining drug treatment—as well as economic hardships. These can be categorized as “deaths of despair,” a term broadly defined by Princeton University economists Anne Case and Angus Deaton as resulting from long-term social and economic decline.

According to a new report by the Well Being Trust, the massive unemployment, mandated social isolation and extraordinary uncertainty Americans are experiencing due to the pandemic will likely cause this level of “despair” to grow. The report forecasts an additional 75,000 “deaths of despair” from alcohol, substance abuse and suicide over the next decade—on top of nearly 70,000 deaths annually from drug overdose. Now, more than ever, we must address the root causes of these deaths by allocating significant funding for both economic development and the expansion of drug treatment and mental health services. Even if the corona virus winds down in the months ahead, the ongoing opioid crisis will test our commitment to those who have been forgotten about for too long.

Note to Congress: Fix the Drug Treatment Funding Snafu

More money could have been flowing to drug treatment programs through the nearly $2 trillion CARES Act approved by Congress for wide-ranging pandemic relief efforts. Unfortunately however, a technicality involving eligibility requirements for Medicare and Medicaid allowed only a small portion of the $175 billion in emergency aid earmarked for hospitals and other healthcare facilities to be set aside for drug treatment centers that serve nearly a million patients (Medicaid alone is the biggest payer of addiction services). Congress could easily fix this bureaucratic glitch—and thereby unleash millions of dollars for drug treatment as facilities anticipate a crush of new patients.

Opioid Lawsuits Target Pharmacy Chains

Despite the pandemic lockdown, opioid lawsuits are continuing nationwide with huge pharmacy chains including CVS, Rite Aid, Walgreens and Walmart coming into the legal crosshairs. After initially eluding close scrutiny, these chains—along with prescription pill manufacturers and major drug distributors—are now being accused of complicity in the opioid epidemic for failing to monitor or regulate the flood of painkillers distributed by their retail outlets. For example, one recently unsealed complaint charges that between 2006 and 2014 more than 64 million doses of oxycodone and hydrocodone painkillers were disbursed in one Ohio county alone—the equivalent of 290 pills for every man, woman and child residing there.

The complaint also details allegations of corporate greed and misconduct at an unprecedented scale. Pharmacy chains purportedly offered bonuses to pharmacists who filled a high-volume of opioid prescriptions, promoted extremely addictive opioids as safe and effective, and helped distributors avoid federal oversight. Whether the thousands of opioid lawsuits will eventually come to trial or end with a nationwide settlement remains uncertain. What is clear, from the latest revelations, however, is pharmacy chains must also be held accountable for the suffering and death they’ve helped to cause.

1st June 2020

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ROSENTHAL REPORT - May 2020

Rosenthal Reports

Pot and the Coronavirus Pandemic

Last month the Rosenthal Report examined the impact of the coronavirus pandemic on the opioid epidemic, looking primarily at how the lockdown has made drug treatment more difficult to obtain, thereby increasing the risk of relapse and overdose for those struggling with substance abuse. This issue focuses on the pandemic’s influence on marijuana consumption, public policy and the future of cannabis legalization.

It came as no surprise that pot sales spiked as states began issuing shelter-in-place orders. Across the country, both in states that have legalized pot and those that have not, consumers stocked up on enough cannabis products to see them through the quarantine. After many states took the unusual step of equating pot shops with grocery stores, pharmacies and gas stations in declaring them an “essential service,” marijuana enterprises ramped up online sales and home delivery options, to help customers avoid social contact.

Massachusetts was an exception. There, Governor Charlie Baker limited sales to medical marijuana, saying he didn’t want tourists flocking to his state specifically to buy recreational cannabis, thus increasing the risk of the virus spreading. As a result, registrations for medical marijuana rose 247 percent in just a few weeks. The marijuana industry also responded to Baker’s decree by suing to have the ban lifted. But a judge ultimately rejected their argument—a clear win for states to regulate markets to ensure public health and safety.

Such defeats have not stopped the industry from pushing its agenda. The cannabis lobby is urging Congress to allow federal coronavirus relief to aid cannabis-related activities, which is now federally prohibited. Such appropriation would be unwise, given the possible link between vaping and smoking marijuana—which can compromise pulmonary function—and negative respiratory outcomes from COVID-19, especially among younger patients.

Looking ahead, the pandemic will likely stall further efforts to legalize marijuana (currently, 22 states allow medical use and 11 states plus Washington, D.C. permit recreational adult use.) Before the virus struck, more than a dozen states—including New York—were set to vote on liberalizing medical and recreational cannabis laws by the end of the year; today, only a few are likely to go ahead. Social distancing rules have stopped petition-signing campaigns by pro-pot advocates, while politicians obviously remain preoccupied with the pandemic.

Given the current state of affairs, the Rosenthal Center repeats its call for a pause on further marijuana legalization. This would provide an opportunity to closely study the effects on consumption patterns and users’ health in legalized states—and time to analyze the impact of existing regulations and restrictions, and determine what further precautions might be needed. If legalization does go ahead it is critical that sensible rules governing the marijuana market be established—based on facts that are unfortunately in short supply.

4th May 2020

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ROSENTHAL REPORT - APRIL 2020

Rosenthal Reports

Combat the coronavirus, but don’t forget the opioid epidemic

The coronavirus pandemic is a public health challenge of unprecedented proportions—one that requires massive resources to treat its victims and stop its spread. At the same time, we must not lose sight of the ongoing and deadly opioid epidemic facing our country, which continues to kill nearly 180 people every day, and has killed more than 400,000 over the past 20 years. Now, as we take on COVID-19, it’s critical for government and healthcare providers to adapt policies for controlled substances that will provide services to people battling substance abuse, a population that is particularly vulnerable at this time.

Social distancing in response to the pandemic is impacting the hundreds of thousands of Americans taking part in medication-assisted treatment (MAT), who must visit drug treatment clinics and other facilities every day in order to receive their addiction-withdrawal medication—primarily the drugs methadone and buprenorphine—as well as behavioral therapy and peer-based coaching. Patients are forced to travel to these sites to pick up their medicine, and then often face long lines and crowded waiting areas, thereby significantly increasing their risk of exposure to the coronavirus. These drug users are then likely to spread the disease among their communities of other drug users. Choosing not to receive treatment is also not a viable option, as doing so would lead to severe withdrawal symptoms. In many cases, access to outpatient care is being limited, and some patients are simply being turned away.

These issues are being addressed head on by the Drug Enforcement Agency and the Department of Health and Human Services. In a prudent move, these agencies have relaxed stringent, long-held regulations limiting access to these critical opioid-based addiction-withdrawal medications. For example, in order to reduce the number of return visits to the clinic, methadone patients are now being provided with four weeks’ worth of take-home doses, with no state or federal sign-off required.

Buprenorphine, a drug that must be taken daily, is now being treated more like a non-addictive medication that can be prescribed by any physician and simply picked up at a pharmacy by the patient. Or, after an initial consultation, the drug can be prescribed through telemedicine after an initial consultation, rather than through subsequent in-person personal evaluations. This also reduces patients’ potential exposure to the virus. In addition, signing up for Medicaid in New York State can now also be done online through telehealth, making it easier to participate in the program’s free drug treatment.

Overall, these critical policy decisions can keep substance abusers supplied with the medications they need while reducing the risk of exposure to the coronavirus. But, as we look ahead to a time when COVID-19 is no longer a threat, let’s seek to retain the regulatory changes that enable wider access to treatment, while also ensuring access to the full range of behavioral treatment services and peer support to reduce the incidence of drug overdose and aid lasting recovery.

6th April 2020

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Dr. Mitch Rosenthal on the Perspectives of Marijuana Legalization in the Democratic Primary

ROSENTHAL REPORT - MARCH 2020

Rosenthal Reports

Where the Democrats Stand on Marijuana Legalization: From Bernie’s Weed for All to Bloomberg’s We Need More Science

With 22 states now permitting the medical use of cannabis, and 11 states plus Washington, D.C., also having made adult-use of recreational pot lawful, the movement to legalize marijuana nationwide has clearly reached a turning point. Additional states, including New York and New Jersey, will address the issue this year as the presidential campaign unfolds. While legalization has so far been a peripheral issue—along with the opioid epidemic, which has killed more than 400,000 Americans—the wide range of proposals from the current field of Democratic candidates reflects a growing polarization between radical strategies and the go-slow approach favored by the Rosenthal Center.

In the progressive lane, Senator Bernie Sanders pledges to sign an executive order on his first day in the oval office directing the attorney general to declassify marijuana as a Schedule One drug, clearing the way for Congress to pass a bill to legalize the drug at the federal level. Next would come decriminalization and the expungement of past convictions. Senator Elizabeth Warren also wants to legalize pot, but would do so by appointing people who support legalization to lead the FDA, Department of Justice and the Office of National Drug Control Policy, and proceeding from there.

Warren and Sanders are more concerned about social and economic justice than the health and well-being of those using the drug. To compensate certain communities that have been disproportionately harmed by harsh drug policies—such as those of color—the Vermont senator promises to use marijuana tax revenue for a $20 billion grant program for “entrepreneurs of color” to start their own pot businesses and growing operations, and $10 billion for victims of the war on drugs. Meanwhile, Warren would support women- and minority-owned cannabis businesses while reducing federal funding for law enforcement in non-legal states that fail to adequately address the issue of racial inequities in marijuana arrest rates.

Among the moderates, Joe Biden has flip-flopped from being an ardent marijuana opponent to grudgingly supporting some sort of legalization. This follows both the party’s general drift in that direction and his disavowal of previous support for criminal justice bills with tough penalties for drug offenses. Biden would now let states set their own policies on legalization while enabling more research to better understand the drug’s impact.

For his part, Mike Bloomberg has also “evolved” on legalization, from once calling it “the stupidest thing anyone has ever done,” to backing decriminalization for low-level offenders, expunging criminal records, and allowing legal states to remain so. Most importantly, Bloomberg is rightly concerned about the effect of pot on teenagers, stating during the South Carolina debate, “it’s just nonsensical to push ahead [with legalization] until we know the science.”

And what if President Trump gets re-elected? In 2016, he said legalization should be left up to the states. But now there are suggestions Trump might take a stronger anti-pot stance to counter the more liberal Democratic proposals, depending of course on whom his opposing candidate might be.

This leadership uncertainty among likely candidates comes as the pro-pot lobby is intensifying its efforts in many states at the same time parent and neighborhood groups are making clear their desire to keep pot out of their communities. The most reasonable approach therefore would be to seek consensus across party lines, acknowledging the reality that marijuana does in fact pose a risk to many individuals, especially young people. And as legalization invariably moves ahead—in one form or another—to protect children by, at the very least, implementing strict and regulations on how, where and to whom pot products are sold.

5th March 2020

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Dr. Mitch Rosenthal on Politicians' Lack of Attention to the Opioid Crisis

Dr. Mitch Rosenthal on the Realities of the Opioid Crisis

ROSENTHAL REPORT - FEBRUARY 2020

Rosenthal Reports

The United States of Marijuana—What to Expect in the Year Ahead

Illinois rang in the new year by legalizing the sale of recreational marijuana. Long lines formed at dispensaries, and government officials began counting all the increased tax revenue from first-day sales that topped $3.2 million. Unlike most of the other states to legalize marijuana, which did so via referendum, Illinois took legislative action. The victory, along with consumer demand and overwhelming popular support, signals the likelihood that more states will loosen their laws or fully legalize pot in 2020—that is, unless more reasonable voices prevail.

The debate in New York State, which centers less on the well-documented potential health hazards and more on how to divvy up the spoils, illustrates the tactics guiding marijuana legalization. After failing last year to pass legislation approving adult-use recreational marijuana, Governor Cuomo is winning over lawmakers by addressing hot-button issues. One is social and economic justice for communities disproportionately penalized by past drug laws. The other is a commitment to spend tax revenue on the “social good”—ironically, for drug treatment and prevention programs—as well as educating people about the risks posed by marijuana.

Let’s consider each of these arguments. Certain communities, such as those of color, have indeed been unduly hurt by harsh drug policies. But ensuring low-income and minority entrepreneurs get a share of the soon-to-boom pot market will not “repair the damages…from the war on drugs,” as Cuomo’s new “Weed Czar,” Norman Birenbaum, has claimed. Rather, it would likely bring more drugs and despair to those communities, whether they are inner city or in rural areas upstate.

Recycling tax revenues from pot sales to treat drug addiction is also a flawed concept. While the lure of tax dollars animates support for legalization among government officials and politicians—including most of the Democratic presidential field—many states that legalized have so far failed to reap the expected tax windfall. Moreover, any additional revenues would no doubt be needed to pay for a host of increased costs—including drug treatment and law enforcement—related to a spike in cannabis use.

In addition, this false argument provides cover for the government’s current failure to adequately fund drug treatment. With the opioid epidemic still raging, and meth and cocaine use on the rise, there is no time to wait for tax money from weed sales to ensure treatment is available for people struggling with substance abuse.

Still, there is some hope for a more sensible approach that focuses on regulation. Birenbaum, himself, has said as much, noting marijuana-related products should not be “marketed or distributed to the most vulnerable members of our community, particularly children.” Cuomo also indicated that new legislation would, as before, include an opt-out clause for counties that don’t want pot stores.

While marijuana possession should be decriminalized, there must be a regulatory structure in place to control how, where and to whom products are sold. In addition, the FDA needs to crack down on vaping devices that contain marijuana, as well as fraudulent claims for the marijuana derivative CBD. Ideally, imposing a national moratorium on further legalization would provide sufficient time to study its impact so far. But given the current political climate and powerful pot lobby, that is unlikely to happen.

5th February 2020

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Dr. Mitch Rosenthal on the Trump Administration Backpedaling on Vaping

Dr. Mitch Rosenthal on the FDA's Lackluster Response to the Vaping Crisis

ROSENTHAL REPORT - January 2020

Rosenthal Reports

The Year in Review: 2019

The year began with a glimmer of hope for some progress combating the opioid epidemic, arguably our nation’s worst public health crisis. Thousands of lawsuits against the opioid industry were set to go to court with potentially large financial settlements ultimately being used to expand drug programs. There were also a number of innovative initiatives, launched by cities and states that were starting to reduce overdose deaths.

But as 2019 came to a close, the overall picture remains grim: Overdose fatalities nationally are expected to reach a near-record level, and settlement talks for the massive opioid litigation have stalled. This year has also seen an outbreak of mysterious vaping-related illnesses, which appear to be linked to marijuana use in illicit e-cigarettes and other vaping devices. In addition, the vaping crisis brought to light widespread teen nicotine use spurred by easier access to these products and their relentless promotion by the intertwined tobacco and vaping industries.

Despite these setbacks, I remain cautiously optimistic our efforts to address these issues—through the Center’s social media platforms, new podcasts and videos, publications and public outreach—will find broader support, and resonate with politicians and policymakers.

A Wall Street Journal editorial in December, for example, called for a pause in marijuana legalization in order to better ascertain the medical and social risks associated with increased use of the drug. This echoes our proposal, published in an Op-Ed in The Hill, for a two-year moratorium on further legalization—a stance that provoked a strong response from both sides of the marijuana debate.

It was also encouraging that, even as pot legalization seemed unstoppable, New York and New Jersey backed away from such legislation. At the same time, a growing number of communities in states with legal weed have protected their neighborhoods by exercising their right to opt out of sanctioning commercial pot shops. This came on the heels of numerous studies highlighting the dangers of increased marijuana use, especially for young people, and the vaping illness epidemic that has so far killed 54 and hospitalized more than 2,500.

Less encouraging is the Government response to the vaping crisis. Although some cities and states have imposed strict regulations on the flavored e-cigarettes that are so popular with teenagers, the Trump administration caved to industry demands and is likely to modify an initial sweeping countywide ban—leaving the measure weakened as more individuals become sick and die. We continue to press for strong leadership to contain e-cigarette use and teen vaping.

Leadership has likewise been lacking when it comes to opioids. With nearly 70,000 Americans expected to die in 2019 from drug overdose—mostly opioid-related—it is troubling that the crisis has received little attention from the Democratic presidential candidates—not to mention President Trump himself. The Rosenthal Center believes the opioid epidemic must be a policy priority; our proposal for $100 billion in government funding over the next decade is a suitable starting point if we hope to reduce overdose deaths and bolster addiction-treatment services.

Adequate support is more critical than ever because we cannot wait for a possible windfall from the opioid litigation. A substantial settlement, with ironclad guarantees the money will be directed exclusively to addiction services, would be appropriate. But efforts to reach a settlement with the companies that flooded the market with 76 billion prescription-painkiller pills between 2006 and 2012 have bogged down in conflict and infighting while the epidemic rages virtually unabated.

As always, the Rosenthal Center is concerned with the care of adolescents and other vulnerable individuals struggling with addiction. The reason for this was made quite clear to me when I visited young people at the Outreach facility on Long Island. What those teens, ages 14 to 17, told us about their experiences vaping the powerful marijuana component THC—often starting in middle school—is hard evidence the nation is facing a new and formidable drug problem that threatens to ensnare the next generation.

We have the knowledge, resources and determination to confront and overcome these challenges. Looking ahead to 2020, the Rosenthal Center will continue to advocate policies to help those seeking treatment to rebuild their lives without drugs. To achieve success, strong leadership is required at every level of government—city, state and federal—as well as the participation of the private sector to establish a comprehensive nationwide anti-drug effort.

7th January 2020

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Dr. Mitch Rosenthal on the Lack of Progress in Combatting the Opioid Crisis

Dr. Mitch Rosenthal on the Need for $100 Billion to Combat Addiction and Support Recovery

ROSENTHAL REPORT - December 2019

Rosenthal Reports

Note to President Trump and Democratic hopefuls: We can’t depend on a windfall legal settlement to combat the opioid epidemic

The opioid epidemic continues to ravage the nation virtually unabated. While a handful of cities and states have managed to reduce overdose deaths, fatalities have spiked in others, and the overall outlook remains bleak. The Centers for Disease Control forecasts a near-record 69,000 drug-related deaths in 2019. Of those, 7 out of 10 will be from opioids—bringing the total number of deaths due to opioids to roughly 400,000 since 1999. Nevertheless, this public health crisis—arguably the worst in American history—still receives scant attention from politicians, even as the 2020 presidential race shifts into high gear.

Attention has instead moved to the complex opioid litigation unfolding across the country. There is widespread hope for a so-called “global settlement” of more than 2,500 cases brought by virtually every state—as well as individual cities and counties—that will provide a massive funding windfall to be used to combat the epidemic.

So far, however, the tangle of court cases, appeals and legal squabbling has led to only a few relatively small lump-sum awards. Among them are a $260 million settlement between four drug companies and two Ohio counties, and a damage award of $465 million to be paid by Johnson & Johnson to the state of Oklahoma. Purdue Pharma is negotiating a settlement of between $10 billion to $12 billion. Other lawsuits are due to go to trial in the coming year.

Those being sued—the opioid makers, drug distributors and pharmacy chains—should without question be held accountable for the more than 76 billion prescription painkillers poured into American communities between 2006 and 2012. They must be made to pay for the misery they’ve inflicted, The question, though, is how much funding—and when—will eventually be made available as a result of these lawsuits to help those who lack access to drug treatment and other services so desperately needed and in short supply.

A legal settlement would not be a cure-all for this devastating epidemic. Meanwhile, the federal government, which has shown a disappointing lack of leadership, must take action now. It should start by allocating $100 billion over the next decade—a plan advocated by Democratic candidates Elizabeth Warren and Amy Klobuchar—to create a strong, effective drug treatment response, including long-term residential care for the most vulnerable addicts. Should settlement money be available in the future, it could be integrated into a broader government effort—if we have one at that point.

We have the capacity, knowledge and resources to fight this epidemic—and to win. But under the Trump administration, Congress has authorized only $6 billion for worthwhile initiatives such as expanding medication-assisted treatment (MAT), increasing availability of overdose-reversal drugs, and making prescription drug monitoring significantly stronger. That is all just a start, and not nearly sufficient given the magnitude of this ongoing crisis, which should be a top priority on every presidential candidate’s policy agenda.

Dr. Mitchell Rosenthal on President Trump's Decision to Back Away from a Flavored E Cigarette Ban

Dr. Mitch Rosenthal Proposes Changes to Safe Injection Sites

The Rosenthal Report - November 2019

Rosenthal Reports

Supervised injection sites for drug users must focus on facilitating movement to treatment

Supervised injection sites providing a controlled and safe environment for drug use are again on the national agenda. A federal court ruling last month removed a legal obstacle to opening the first such U.S. facility, in Philadelphia, which is struggling with the opioid epidemic and a skyrocketing rate of overdose, as are other American cities. While it’s not certain when this might happen, questions remain regarding how such sites will help move users into drug treatment.

These sites do not provide drugs to addicts, but rather offer access to clean needles, and health professionals are on hand to administer anti-overdose drugs as well as provide counseling. Supervised sites have operated for years in Canada, Australia and Europe and some studies show they can reduce overdose fatalities as well as the transmission of infectious diseases through injection and drug-related criminality.

Yet, while the goal is to save lives, such harm-reduction strategies fall short when it comes to ensuring that users opt for treatment. My experience suggests that after a user injects drugs or is rescued from an overdose at a safe site, there is insufficient engagement to end the cycle of drug abuse.

Safehouse, the Philadelphia nonprofit sponsoring the supervised site, would do this by counseling users and promoting medication-assisted treatment (MAT), which combines withdrawal drugs and behavioral therapy. But it leaves the final decision up to the patient, believing that by establishing a trusting relationship with the user, he or she will more likely agree to give treatment a try.

As noted in a previous Rosenthal Report (August, 2018), what is missing from this approach is a mindset that all patients can be helped to enter treatment. We also propose to limit the time and access to the facility to 60 days to discourage continued drug use without agreeing to treatment. By the end of this time, and after extensive interaction with peer-based counselors and addiction professionals, there would be an expectation that the patient is ready to enter treatment to become drug free.

We encourage the safehouse project in Philadelphia, but it must have a research protocol. And at the same time, they should also run a pilot project along the lines I have suggested that can transform a supervised injection center into a treatment induction center. We need to know which will work better and prove to be more beneficial as part of a comprehensive anti-opioid strategy.

1st November 2019

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Dr. Mitch Rosenthal on the Need to Support a FDA Ban on Flavored E Cigarettes

The Rosenthal Report - October 2019

At the end of September, the number of cases of respiratory illness linked to vaping rose sharply—to 805 from 530 in a single week—and 12 persons had died, the Centers for Disease Control and Prevention reported. With the mysterious disease now present in 46 states and territories and nearly 11 million Americans vaping on a regular basis, the problem of vaping-related illnesses has become a national health emergency that requires urgent action—and this is most easily accomplished on the state level.

Massachusetts has taken the lead on this issue by placing a four-month ban on sales of e-cigarettes. This includes online and in-store sales of all vaping products and devices as well as the pods that contain nicotine or THC—the psychoactive component of marijuana which might play some role in the illnesses. The Rosenthal Center urges all states to enact a comprehensive ban along the lines of the Massachusetts restrictions as the most effective way to safeguard public health in the face of a baffling dilemma and slow federal action to contain it.

Doctors first recognized some linkages between acute respiratory distress and e-cigarettes as early as 2012. But only recently have health officials begun comparing data and patient histories to better understand the connections to vaping. While the cause is still unknown, there are some patterns: The ailments mostly strike young men with a median age of 19 who have used e-cigarettes with THC or nicotine, and the lung damage many of them suffer is so severe that many end up in the ICU or on ventilators. The epidemic also coincides with a surge in popularity of e-cigarettes among teenagers, as a recent survey found that 21 percent of 12th-graders vaped in 2018—almost double the number who had in 2017.

City, state and federal health agencies—as well as the $2.6 billion e-cigarette industry—are belatedly responding to the escalating crisis. The Food and Drug Administration (which has yet to conduct safety tests or trials on vaping products) has proposed a ban on the flavored e-cigarettes preferred by young people, and the CDC has urged teens and other consumers to stay away from bootleg vaping devices and street cannabis. Walmart has stopped selling e-cigarettes and Juul Labs, the industry leader in e-cigarettes, has pulled controversial advertising that was clearly targeting young people.

Unfortunately, these efforts are a patchwork solution to an extremely complex problem. To truly protect the public, we need a tough crackdown on e-cigarette sales across the board in every state, to allow time for doctors and other medical experts to determine the cause (or causes) of the illnesses and for policymakers to `cigarette ban might pose difficulties for those who use these products as a smoking-cessation aid, it is absolutely necessary to confront this problem. Eventually, we must also enact strong legal measures to curb teenage vaping—such as establishing a nationwide legal age of 21 to buy e-cigarettes—to prevent a new generation from being addicted to vaping nicotine or marijuana.

The Rosenthal Report - September 2019

Nationwide opioid litigation appears to be entering a decisive phase, with one of the main defendants—the opioid maker Purdue Pharma—in settlement talks valued at as much as $12 billion. Purdue is among some two-dozen prescription opioid manufacturers, drug distributors and pharmacy chains being sued by state and local governments in roughly 2,000 lawsuits. The companies are accused of fueling the epidemic that has led to hundreds of thousands of opioid-related overdose deaths during the last two decades.

While the terms of a Purdue deal remains in flux, it is clear that these companies acted in a vile and immoral way. Any settlement should reflect the magnitude of the misery they have inflicted on families and communities across the country. Equally important, the ultimate outcome of this entire wave of lawsuits will determine how we combat the epidemic over the next decade—and what resources are available to end this public health crisis.

THE Johnson & Johnson case

Momentum in the Purdue lawsuits follows last month’s resolution of an opioid case in Oklahoma against Johnson & Johnson (the only such case to go to trial). The healthcare giant—which was the leading supplier of the chemical ingredient used to make prescription opioid painkillers—was ordered to pay the state $572 million in damages for aggressive marketing tactics similar to those employed by Purdue and others. Separately, out-of-court opioid settlements ranging from $10 million to $270 million have also been reached ahead of a planned October court date in Cleveland for consolidated cases.

These numbers are important, because a Purdue agreement could pave the way for a master opioid settlement on a scale similar to the 1998 Master Tobacco Agreement, in which cigarette companies agreed to pay $246 billion over 25 years for anti-tobacco initiatives. As such, many of the opioid plaintiffs are already disagreeing over the terms of the proposed settlement and how to divvy up the money they stand to be awarded.

Money for drug treatment, not repairing potholes

The Johnson & Johnson decision, which the company is appealing, stipulates in vague language that the money should go to “abate the opioid crisis.” With pressure mounting to reach a deal, we must ensure that any agreement includes adequate compensation for the crime. In addition, there must be ironclad guarantees the money is used for addiction treatment—and not siphoned off by cities and states for general operating expenses, which is what happened following the tobacco settlement.

As the opioid epidemic continues to rage on while other drug crises are escalating, the need for this money only becomes more urgent. Although 2018 saw a slight decrease in prescription opioid misuse and cases of opioid use disorder, according to the latest findings from the National Survey on Drug Use and Health, an estimated 70,000 Americans died of drug overdose last year, three-fourths of which were opioid-related. The survey also noted troubling increases in methamphetamine use and marijuana-use disorders among young people.

Stumbling blocks to reaching a deal

The price that defendants should pay for their role in flooding America with more than 76 billion opioid painkillers while misleading patients about the addictive nature of the drugs is difficult to calculate. Some state attorneys general say the proposal in its current form falls short (prosecutors in the Johnson & Johnson case, for example, had sought $17 billion for a 30-year anti-opioid effort). Purdue sold $36 billion of OxyContin since introducing the drug in 1996 and the firm’s founding Sackler family has profited handsomely.

The proposed settlement would see the family cede its ownership stake in Purdue and contribute $3 billion of its own money for damages, which some say is not enough and would leave the Sackler fortune largely intact. Another possible sticking point: the proposed deal is tied to potential profits that Purdue—which would be restructured as a “public beneficiary trust”—continues to earn from selling OxyContin, the prescription painkiller that contributed to the epidemic. Purdue would also donate a number of addiction treatment drugs it is developing but are not yet approved by the Food and Drug Administration.

Whether the other parties chose to fight in court or make a deal is unclear, as is any final estimate of damages. Regardless, we need to establish a national action plan to ensure any settlement windfall—however much that ends up being—isn’t diverted. By significantly expanding a wide range of affordable and accessible drug treatment options, including long-term residential and medication-assisted treatment, we can help all those struggling with substance abuse and begin to close this tragic chapter of our history.

4th September 2019

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Dr. Mitch Rosenthal on the Risks of Overprescribing Opioids to Children for Tonsillectomy

Dr. Mitch Rosenthal on the Lack of Attention to the Opioid Crisis in the Current Political Discussion

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5th August 2019

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Dr Mitch Rosenthal on the Need for Comprehensive Action Plans to Combat the Opioid Crisis

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3rd August 2019

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The Rosenthal Report - August 2019

Rosenthal Reports

AN AMERICAN OPIOID SCANDAL: HOW THE DRUG INDUSTRY FUELED THE OPIOID EPIDEMIC WITH 76 BILLION PAIN PILLS

As the opioid epidemic escalated, the broad outlines of the crisis became generally well known. Pharmaceutical companies marketed highly habit-forming drugs as non-addictive, pharmacies filled prescriptions without question, and doctors wrote excessive opioid prescriptions even for minor ailments such as a sprained ankle. Yet while the trajectory of the epidemic was clear, the full extent of the complicity shared by drug makers, drug distributors and pharmacies has not been entirely transparent—until now.

According to newly released federal data, the major players in the drug industry flooded the nation with roughly 76 billion prescription painkiller pills between 2006 and 2012, fueling an epidemic that led to 100,000 overdose fatalities during these years. This data and related documents reveal the greed and negligence of these companies—while also serving as a warning we must heed if we are to prevent another epidemic.

Pumping pills to America

The previously undisclosed Drug Enforcement Agency (DEA) data that has come to light as part of opioid-industry lawsuits reveal the unprecedented scale of the pill pushing. Enough oxycodone and hydrocodone painkillers were distributed to supply every adult and child in the country with 36 pills per year. In small towns such as Norton, Virginia, the equivalent of 306 pills for each of the 3,900 residents were distributed. As fast as opioid manufacturers produced the pills, pharmacies obligingly handed them out: At one point, a Walgreens in Port Richey, Florida—with a population of only 2,831 residents—was ordering 3,271 bottles of oxycodone each month (or nearly one bottle of painkiller pills per person.)

The system fails, and death rates spiral

Not surprisingly, the death rates from opioids soared in areas saturated with those billions of pills. An analysis by the Washington Post—which, along with the Charlotte Post-Gazette in West Virginia fought to release the DEA data against drug company objections—found that the most fatalities occurred in rural communities in West Virginia, Kentucky and Virginia. But despite the spike in opioid-related deaths, the drug makers, distributors and pharmacies—including such national chains as CVS and Walgreens as well as Walmart superstores—did little to intervene. Compliance and monitoring systems required by law and designed to flag suspicious orders and prescription flows, were routinely overlooked. Company emails suggest that executive were unconcerned about the massive outflows of pills and the number of overdose deaths as they pursued greater profits.

Lawsuits target key drug industry firms

The disturbing data and documents were unsealed as part of roughly 2,000 lawsuits brought by towns and counties against more than two-dozen firms—including Purdue Pharma, which introduced OxyContin in 1990—that have since been consolidated into one case in Cleveland. Meanwhile, another lawsuit filed last month argues that the drug distributors and pharmacies are also to blame for helping move all those pills, opening a new frontline in the legal battle. (The drug companies, for their part, say the epidemic was the result of doctors overprescribing the drugs and customers abusing them.)

As assessed in previous Rosenthal Reports, the lawsuits might end in a master settlement on the same scale as the $206 billion tobacco industry agreement of 1998. Should that come to pass, I will continue to urge all parties involved in the lawsuits to guarantee sufficient funding be allocated directly to substance-abuse initiatives and drug treatment.

However, with an estimated 70,000 overdose deaths in 2018 alone—two-thirds of which were linked to opioids—we cannot rely solely on a potential legal settlement for future funding of substance abuse services. Regardless of what results from with those lawsuits, the federal government should immediately allocate $100 billion over the next decade for programs to expand education, prevention and most importantly, treatment.

Action Plan

Based on what we have recently learned about the inner workings of the drug industry, we must also take the following steps:

-Ensure that prescription-monitoring regimes imposed over the past few years remain in place and are strengthened, if needed. These strict, statewide controls successfully track the number of painkiller prescriptions, and alert officials to possible abuses by doctors, pharmacies and/or patients.

-Improve addiction-medicine education in medical schools, providing students with a solid grounding and practice in the field, and broader awareness of patient issues and concerns. Doctors must continue to speak openly and frankly with patients about all aspects of pain medication if they are to secure informed consent.

-Give the DEA the resources, manpower and authority to effectively enforce the rules that pertain to the manufacture, distribution and dispensing of legally produced controlled substances, such as painkillers.

As these latest revelations have helped blow the lid off the American opioid scandal and expose for the first time the depth of the drug industry’s involvement in this deadly public health crisis, it is time to bring this hideous chapter in our history to a close. With the knowledge and information available to us now, and with the proper regulations and oversight in place, we can end the current crisis and be well positioned to prevent the next.

30th July 2019

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Dr Mitch Rosenthal on the Susceptibility of the Adolescent Brain to Drugs and Addiction

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29th July 2019

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Dr Mitch Rosenthal on the Overprescription of Opioid Medication in the United States

The Rosenthal Report - July 2019

Rosenthal Reports

SPECIAL REPORT: TEENS AND THE NEW ERA OF POWERFUL, LEGAL MARIJUANA

Cannabis is now legal in 43 states plus Washington, D.C., including 33 for medical marijuana use alone and 11 for recreational. Polling shows strong public support and politicians increasingly endorse legalization based largely on the widespread belief that marijuana and other pot-related products are relatively benign—or even beneficial for a host of ailments—with few, if any, potential risks. But what, in fact, has been the impact of this new era of easily accessible, highly potent pot—especially on such vulnerable groups as teenagers?

To find out, we spoke to a dozen teens between the ages of 14 and 17 at Outreach, an adolescent treatment center on Long Island. What the youngsters told us—about how they started using, the constant peer pressure they face, their progression to stronger drugs, and their struggles trying to stop—painted a disturbing portrait of a younger generation caught up in a new and dangerous level of substance abuse.

For the young people at the Outreach facility, their first exposure came as early as middle school, where they would, for example, gather in bathrooms to use e-cigarettes and vape nicotine as well as cannabis. “You easily get pulled into something new because everyone is doing it,” one girl recalled. In addition to the nicotine cartridges that come in such wildly popular e-cigarette brands such as Juul, the students would vape pre-packaged, liquid-filled pods containing up to 90 percent THC (the psychoactive component of cannabis). These products are currently illegal in New York State but can be easily obtained through intermediaries in states where recreational marijuana has been legalized, the teens said.

The impact of vaping today’s stronger pot is immediate. “You get really high, really fast, and you just want to stay high,” one teen said. And as tolerance builds, users turn to any number of new cannabis offerings that pack an even stronger punch. These include wax or dabs, as well as Moon Rocks—a potent strain of cannabis dipped in hash oil and sprinkled with cannabis resin. Noted one boy, “If the drugs don’t work anymore you move on to the next strongest thing—to whatever messes you up.”

The teens at Outreach talked about what it’s like to get high using these more concentrated marijuana products, with symptoms including blackouts, racing heartbeat and difficulty breathing. One girl stole money from her parents to buy the drugs, and many withdrew from their normal teenage routines and friendships, and eventually even gave up going to school. Teens are brought to Outreach by their parents, by referral from the juvenile justice system, or by their school—both institutions are becoming more and more concerned about teen marijuana use.

Research confirms what the young people at Outreach described. Vaping nicotine is surging in popularity in this age group, with more than one-third of 12th graders reporting having vaped in 2018, up 10 percent from the previous year, according to the Monitoring the Future Survey. In addition, more than 13 percent of these 12th graders vaped cannabis compared to 9.5 percent in 2017. As legalized marijuana becomes more accessible and new products flood the market, “[the drug] is increasingly the first substance in the sequence of adolescent drug use,” a 2018 Columbia University study reported in the journal Drug and Alcohol Dependence.

John Venza, vice president of residential and adolescent services at Outreach, said the teens’ experience with marijuana follows a new pattern of earlier onset and faster progression. “There is a quick introduction through vaping nicotine and then THC and then a comfortable progression to products that hit like a ton of bricks,” Venza explained. These include edibles such as Pot Tarts, a pot-filled version of the popular packaged pastry, or candies with wrappers designed to look like such common confections as Snickers bars or Reese’s peanut butter cups.

Parents have traditionally been the first line of defense against teen drug addiction. Today, however, many of them take a more hands-off approach. “They think it’s just pot and so not a big problem, and that sets the tone for not getting involved,” Venza said. What’s more, many parents underplay the difference between what drugs are now and what they were when they were adolescents. With legalization, according to Venza, ”pot has been normalized.”

Action Plan:

Listening to these remarkably smart and self-aware young people is moving and provides hope they will succeed.

It is now our responsibility to take action. While pro-marijuana legislation has recently stalled in New York and New Jersey, the legalization trend is likely to continue. The Rosenthal Center supports a comprehensive strategy to deal with the availability of new cannabis products and the resultant uptick in teen marijuana use:

Education and Prevention Programs:

Focused on students, parents, teachers, school officials, social workers, therapists, and anyone who regularly interacts with young people, these programs must make people fully aware of the risks and dangers of today’s more-powerful marijuana and its impact on the developing brain, the warning signs of drug use, as well as the specific harms from vaping cannabis.

Government Oversight:

As legalization moves ahead, we must insist on strict rules and regulations for how and where marijuana is sold, including what products are available; age limits; clear and concise warning labels and information about dosage and interactions. We will need adequate safeguards to prevent it from being explicitly marked to young people.

Treatment:

While our main focus today has largely been on the devastating opioid epidemic, we must now allocate additional financial resources and manpower to significantly expanding access to specialized treatment options for teenagers. And because it is unlikely we will be able to prevent the legalization of marijuana in New York State, we should also aim to educate parents, teachers, young people and the general public on how teen drug use remains a real and critical problem—one that would be tragic to ignore.

3rd July 2019

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The Rosenthal Report - June 2019

Rosenthal Reports

THE OPIOID EPIDEMIC ENTERS THE 2020 PRESIDENTIAL RACE

In 2017, there were a record 70,000 drug overdose deaths in the United States, two-thirds of which were linked to opioids—and data for both 2018 and this year shows no significant reduction in fatalities. Yet as the 2020 Presidential race kicks into high gear, only two of the 24 Democratic candidates—Senators Elizabeth Warren and Amy Klobuchar—have announced comprehensive strategies to fight the opioid epidemic. Given the Trump administration’s lackluster response to the crisis, the Democrats are missing an opportunity to both raise greater awareness of the drug crisis and build political momentum to find and fund solutions.

Sen. Warren’s proposal is based on the Comprehensive Addiction Resources Emergency (CARE) Act, a bill she and Rep. Elijah Cummings introduced in Congress in 2018. It calls for $100 billion to be spent over 10 years to boost substance-abuse treatment and other anti-drug initiatives—a scale and scope of funding supported by the Rosenthal Center. Money would go to both increase access to drug treatment and the use of overdose-reversal drugs, as well as such measures as research into innovative treatments and training for health care staff, among other measures. To fund the program, Warren proposed instituting a new wealth tax on the super rich.

Sen. Klobuchar’s plan also allocates $100 billion over a decade to address the opioid epidemic as well as alcohol misuse and mental health services. It includes smart initiatives in prevention, treatment and recovery such as better training for doctors to recognize the early warning signs of addiction, transitional housing for recovering addicts, and treatment instead of incarceration for nonviolent drug offenders. Funding would come from charging opioid manufacturers a fee for every milligram of drugs they sell—similar to a recently approved opioid tax in New York State—and reaching a “master settlement agreement” from the nearly 2,000 lawsuits that have been filed against pharmaceutical companies and distributors.

For the most part, both proposals are thoughtful and incorporate many of the best practices of addiction care. Most importantly, they aim to get more individuals with substance use disorder intro treatment.

Today, only one in five addicts receive specialty treatment and fewer than half of all treatment facilities offer medication assisted treatment (MAT), which combines addiction-withdrawal medications and peer-based counseling. Compared with the Trump administration’s failed attempts at curbing the epidemic, the Democratic proposals would likely have more impact than anything the government has previously attempted.

Whether these strategies are ever enacted, however, is as uncertain as the election itself. The ambitious CARE Act never gained much traction in either the House or Senate. Lacking strong leadership from the White House, Congress opted instead to boost prescription-drug monitoring and law enforcement, allocating overall around $6 billion in short-term funding—a fraction of what would be appropriate.

While it’s still early days in the campaign, I urge other Democratic candidates to take a forceful stand as well. Elevating the opioid epidemic onto the high profile platform of a presidential campaign—and taking the message to areas of the country hardest hit by the opioid epidemic, as Warren has done—will ensure the issue remains at the forefront of public debate and policymaking.

4th June 2019

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New Opioid Taxes & Employer-based Solutions to the Opioid Epidemic

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28th May 2019

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The Rosenthal Report - May 2019

Rosenthal Reports

Can taxes help combat the opioid epidemic? New York State intends to find out

New York State is addressing the opioid epidemic with a first of its kind opioid tax on manufacturers and distributors of prescription opioids, as well as a tax credit for businesses that employ drug users who are either in recovery or have completed treatment. The measures were enacted in the most recent budget to raise additional funding for treatment programs, and encourage more people to enter treatment, and could also serve as a model for other states at a time when substantial federal funding is lacking.

Taxing the opioid makers and distributors that are largely responsible for this crisis is the right thing to do, and could yield up to $100 million annually for anti-drug programs. However, because budget language stipulates this money is “intended” for drug treatment programs, there’s no guarantee opioid tax revenues will actually be used to help those struggling with addiction and opioid abuse. Instead, the revenues go into the state’s general fund, which legislators will haggle over how to spend at a later date. The likely result is allocation of only a portion of the $100 million to anti-drug programs through the state Office of Alcoholism and Substance Abuse (OASAS).

With neither Governor Cuomo nor state legislators able to do anything about this now, we are stuck in the frustrating position of having no assurance the revenue being generated specifically for drug services will ultimately reach the people most in need. This is especially disturbing when considering that more than 4,100 New York State residents died from drug overdose in 2017, up from 3,638 in 2016. The Rosenthal Center urges the political leadership in Albany to close this loophole in the budget’s language to ensure opioid tax revenue is eventually allocated solely to drug treatment.

The second budget measure – a $2,000 employer tax credit for each new or existing employee in a state-certified recovery program - is a winner. For substance abusers, the promise of a real job is a powerful incentive and an attainable goal to strive for while getting off drugs. The tax credit is particularly important for smaller firms, including many in upstate regions hit hard by the opioid crisis that have trouble finding drug-free workers. Backed by an initial $2 million in state funding, this initiative will certainly gain a foothold across New York – as it is a win-win for companies, communities and individuals who are determined to rebuild their lives and stay clean.

This program is similar to a successful one I helped design for Belden, an international manufacturing company. Known as Pathways to Employment, it was also structured around such addiction-care best practices as early detection and evaluation, free treatment, social support and incentives – including a job that can lead to stability.

At this early stage, New York’s tax reforms might seem like just a footnote to bigger efforts underway to fight the opioid epidemic and reduce overdose fatalities. But if adopted on a wider scale, including by the federal government, the results would likely have an extraordinary impact. Although these taxes alone won’t end the opioid epidemic, they will help plug gaps in funding due to insufficient federal allocations, expand treatment options and enable more people to enter treatment as part of a comprehensive anti-drug strategy.

3rd May 2019

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The Rosenthal Report - April 2019

In a disturbing development, President Trump is backing a Texas lawsuit that would invalidate the Affordable Care Act (ACA), slashing funds for substance abuse treatment and leaving more than 30 million Americans without health insurance. That includes those who purchased insurance plans through ACA marketplaces, and low-income beneficiaries covered under ACA’s Medicaid expansion. Even more troubling, as we grapple with the opioid epidemic, rescinding ACA would end the requirement that insurance companies cover substance abuse treatment.

ACA and the Medicaid expansion have had a substantial impact on treating addiction at a time when more than 70,000 Americans are expected to die this year from drug overdose. Medicaid pays for a quarter of all addiction treatment in the U.S., including prescriptions for two medications used to treat opioid withdrawal. This has led to a welcome increase in the number of treatment programs and primary care doctors who are able to prescribe withdrawal medications, an essential component of medication-assisted treatment (MAT) which combines anti-craving drugs with behavioral therapy and peer-based counseling.

So, more than two years into the Trump administration, we are still looking into the abyss – without strong leadership and massive funding for an anti-drug effort – and are now facing the threat to dismantle the ACA. Some believe funds might be forthcoming from a settlement of the opioid lawsuits now underway in many states against opioid makers. But in the only settlement so far, Purdue Pharma agreed to pay $270 million to Oklahoma for opioid addiction research and treatment, a fraction of the $20 billion in damages the state had sought.

We cannot wait for lawsuits when, on average, 130 Americans die every day from drug overdose. The Trump administration is ignoring a national crisis when we have the resources to launch a national campaign to help those suffering from substance abuse, and to stop the tragic loss of life.

3rd April 2019

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Dr. Mitch Rosenthal's Good Day NY Addiction and Best Treatment Practices Segment

East Hampton Star: Medical Marijuana

Medical Marijuana

East Hampton

March 7, 2019

To the Editor:

Your article “Suffolk County Debates Legalized Marijuana” (Feb. 26) covered the County Legislature’s hearing on Gov. Cuomo’s plan for marijuana legalization very well. It provided valuable insights on the arguments to be made for and against legalization, and on the right of local governments to opt out of the statewide plan and retain local prohibition of the marijuana trade.

As a psychiatrist who has been treating addiction for more than half a century and an East Hampton homeowner and part-time resident, I found the debate deeply troubling. It highlights the current dilemma of making decisions about the use of marijuana when so much about modern marijuana and its impact on users and communities is still not known. Equally troubling is what we now do know about the drug and the likely effects of legalization, to which the partisans of legalization are either unaware or indifferent.

The general public believes marijuana is a benign psychoactive drug, while today’s marijuana is powerful and dangerous, especially to the developing brain of adolescents and users vulnerable to mental illness. Consumers can already buy marijuana products with no idea of how much T.H.C., pot’s psychoactive component, it contains. Medical marijuana marketers claim that salves, oils, and even cosmetics and beverages made with C.B.D., a non-psychoactive marijuana component, can relieve stress and anxiety and aches and pains — even help Alzheimer’s disease. But there is, in fact, only one drug derived from the cannabis plant approved by the F.D.A. and it is for a rare childhood epilepsy.

With so much research now underway and so much risk in the rush to legalize, the most rational response to the governor’s proposal is not to opt out, but to oppose it.

MITCHELL S. ROSENTHAL, M.D.
Dr. Rosenthal was the founder of the national Phoenix House programs and today is the president of the Rosenthal Center for Addiction Studies. Ed.

18th March 2019

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President Trump Lacks Opioid Crisis Strategy

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14th March 2019

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Gottlieb's Disappointing Departure from FDA

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12th March 2019

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The Rosenthal Report - March 2019

Rosenthal Reports

IF THE OPIOID LAWSUITS PRODUCE A FUNDING WINDFALL, WE MUST BE PREPARED TO SPEND THE MONEY WISELY

We are fighting the opioid epidemic on many fronts, with prevention, education, law enforcement and treatment. The battle is also being waged in state and federal courts, for drug overdose is now the leading cause of death for Americans under the age of 50. Some 37 states and more than 1,500 cities and counties are currently suing the makers and distributors of prescription painkillers for contributing to an epidemic that kills more than 70,000 Americans a year. The cases might well end with an agreement on the magnitude of the massive 1998 financial settlement against tobacco companies, considering that the opioid industry could be worth as much as $35 billion annually by 2025. Such a result could provide funding on a scale needed to help bring the epidemic under control - but only if we have the right strategy and legal agreement.

Prosecutors say pharmaceutical firms including OxyContin-maker Purdue Pharma, played down the addictive risks of these drugs. These false marketing practices duped doctors and patients into believing that opioids were relatively benign, and failed to monitor excessive prescribing and distributions (the companies have denied any wrongdoing). As details of the lawsuits emerge, and the scope of alleged negligence is revealed, these cases resemble those against cigarette makers. In exchange for ending all legal liability, those defendants agreed in 1998 to pay the states a minimum $206 billion over 25 years for lifesaving tobacco control efforts, and continue making annual payments in perpetuity that correlate to the market share of each company.

As we look toward a possible opioid settlement, we’d best recall what happened to all that tobacco money. Unfortunately, the states were not legally required to use the funds for anti-tobacco initiatives. And as a result the vast majority of states diverted the windfall to public works and other projects (funds were even used to subsidize tobacco farmers in North Carolina.) An analysis by the American Lung Association on the 20th anniversary of the agreement found that states today are spending less than 3 cents of every settlement dollar per year on anti-tobacco programs. Only one state funded these programs in 2018 at levels recommended by the Centers for Disease Control. While tobacco use has fallen dramatically since the settlement, much more could have been accomplished.

We must not repeat that mistake. If the opioid cases end with substantial and continuing funding for anti-drug programs, the settlement should contain language that guarantees payments are used for substance abuse initiatives. Programs must focus on prevention, education and early intervention strategies. They must substantially expand access to a broad range of treatment options including long-term residential and behavioral therapy, along with medication-assisted treatment (MAT). The money could be used to establish community-based clinics and treatment facilities in hard hit rural areas, and also in prisons. Funding might also support treatment programs to help private companies provide treatment to job applicants who fail drug tests like the program I helped design for Belden.

The Rosenthal Center has long advocated $100 billion in government funding over the next decade to fight the opioid epidemic, but Congress has only appropriated a fraction of that amount. A substantial opioid settlement might reach the level I believe is appropriate, with those drug makers accused of contributing to the crisis and tragic loss of life paying for a comprehensive and well-organized nationwide effort to end the suffering.

1st March 2019

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To ensure public health and The Hill: Safety, Impose a Two-Year Moratorium On Marijuana Legalization

Reckless Pursuit of Marijuana Legalization and Commercialization

We Need Treatment Funding, Not a Border Wall, to Solve Drug Crisis

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5th February 2019

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The Rosenthal Report - February 2019

Rosenthal Reports

Mr. President: Stop Politicizing the Opioid Epidemic

More than 140,000 Americans have died from drug overdose since President Trump took office more than two years ago. Now the president is exploiting the crisis in his battle with Congressional Democrats over funding for a wall along the southern border. The president, ignoring or misconstruing the government’s drug trafficking data, said last month that drugs including meth, heroin, cocaine and fentanyl are coming over the border in a “vast pipeline” but could be “stopped cold” by a wall.

In fact, an estimated 35 percent of overdose deaths are due to legal prescription opioids manufactured by U.S. companies; they are not brought over the border by drug mules. The Drug Enforcement Agency’s 2018 Threat Assessment stated that while the majority of heroin and cocaine does enter the country along the southwest border with Mexico, those drugs are transported in cars, trucks and tractor-trailers at legal ports of entry and official crossing points, not at remote desert locations. Meanwhile, much of the fentanyl responsible for the spike in U.S. overdose is manufactured in labs in China and shipped here by mail.

The Trump administration has a poor record of responding to the opioid epidemic, aside from declaring it a public health emergency in 2017, which was largely a formality. At a time when innovative programs in many cities and states are starting to show positive results, it is wrong to divert attention from the most important needs: increasing education and prevention, reducing overdose fatalities, and expanding access to treatment. Instead of politicizing the opioid crisis, what we really need in Washington is strong leadership and a federal commitment to providing more resources, manpower and funding. Last year Congress appropriated around $9 billion for the epidemic, but a more appropriate amount would have been $100 billion to address this national tragedy over the next decade.

Big Pot sets up shop

For some time now, the Rosenthal Center has been concerned about the evolution of the legal marijuana market into a powerful industry known as Big Pot. Backed by politicians, investors, growers, marketers and retailers, Big Pot is here and open for business. As noted in the Wall Street Journal’s Heard on the Street column, “serious money is now flooding into marijuana,” with $7.9 billion raised by cannabis companies globally in just the fourth quarter of 2018, double the amount raised in all of 2017. Tobacco and liquor companies are particularly keen to establish a foothold in what could be a $50 billion U.S. market by 2025.

That forecast seems plausible: In 2018 consumers in California placed an order for a cannabis product every 8 seconds, according to an analysis of first year medical and recreational sales in the state. Women and baby boomers are driving growth, the report by cannabis platform Eaze found. Products with CBD – the non-psychoactive component of marijuana – are especially popular due to purported “wellness benefits” such as relief from anxiety, stress and pain. Users of these products might truly believe they work. But other than the one FDA-approved, CBD-based drug for a rare form of epilepsy, there’s no definitive scientific evidence that CBD oils, creams and chocolates really accomplish what is claimed. Posing even more uncertainty and risk are potent marijuana products with up to 25 percent THC, the drug’s psychoactive component, which are also popular.

Unlike tobacco and alcohol products and pharmaceuticals, legally purchased marijuana does not carry warning labels, dosage recommendations or information about potential side effects – about which we still lack sufficient information. More research is needed, and that is why I am renewing my call for a two-year moratorium on legalization to provide the opportunity to study the impact so far on health and social behavior. Complete legalization of marijuana across the country may be inevitable. That’s why consumers – especially parents of adolescents – need to know more about what Big Pot is selling.

1st February 2019

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VIDEO on Alex Berenson's Book, Tell Your Children

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10th January 2019

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Marijuana Is More Dangerous Than You Think

Articles

WSJ: Essay

Marijuana Is More Dangerous Than You Think

As legalization spreads, more Americans are becoming heavy users of cannabis, despite its links to violence and mental illness

By Alex Berenson
January 4, 2019

Over the past 30 years, a shrewd and expensive lobbying campaign has made Americans more tolerant of marijuana. In November 2018, Michigan became the 10th state to legalize recreational cannabis use; New Jersey and others may soon follow. Already, more than 200 million Americans live in states that have legalized marijuana for medical or recreational use. Yet even as marijuana use has become more socially acceptable, psychiatrists and epidemiologists have reached a consensus that it presents more serious risks than most people realize.

Contrary to the predictions of both advocates and opponents, legalization hasn’t led to a huge increase in people using the drug casually. About 15% of Americans used cannabis at least once in 2017, up from 10% in 2006, according to the federal government’s National Survey on Drug Use and Health. By contrast, almost 70% of Americans had an alcoholic drink in the past year.

But the number of Americans who use cannabis heavily is soaring. In 2006, about 3 million Americans reported using the drug at least 300 times a year, the standard for daily use. By 2017, that number had increased to 8 million—approaching the 12 million Americans who drank every day. Put another way, only one in 15 drinkers consumed alcohol daily; about one in five marijuana users used cannabis that often.

And they are consuming cannabis that is far more potent than ever before, as measured by the amount of THC it contains. THC, or delta-9-tetrahydrocannabinol, is the chemical responsible for the drug’s psychoactive effects. In the 1970s, most marijuana contained less than 2% THC. Today, marijuana routinely contains 20-25% THC, thanks to sophisticated farming and cloning techniques and to the demand of users to get a stronger high more quickly. In states where cannabis is legal, many users prefer extracts that are nearly pure THC.

Cannabis advocates often argue that the drug can’t be as neurotoxic as studies suggest because otherwise Western countries would have seen population-wide increases in psychosis alongside rising marijuana use. In reality, accurately tracking psychosis cases is impossible in the U.S. The government carefully tracks diseases such as cancer with central registries, but no such system exists for schizophrenia or other severe mental illnesses.

Some population-level data does exist, though. Research from Finland and Denmark, two countries that track mental illness more accurately, shows a significant increase in psychosis since 2000, following an increase in cannabis use. And last September, a large survey found a rise in serious mental illness in the U.S. too. In 2017, 7.5% of young adults met the criteria for serious mental illness, double the rate in 2008.

None of these studies prove that rising cannabis use has caused population-wide increases in psychosis or other mental illness, although they do offer suggestive evidence of a link. What is clear is that, in individual cases, marijuana can cause psychosis, and psychosis is a high risk factor for violence. What’s more, much of that violence occurs when psychotic people are using drugs. As long as people with schizophrenia are avoiding recreational drugs, they are only moderately more likely to become violent than healthy people. But when they use drugs, their risk of violence skyrockets. The drug they are most likely to use is cannabis.

The most obvious way that cannabis fuels violence in psychotic people is through its tendency to cause paranoia. Even marijuana advocates acknowledge that the drug can cause paranoia; the risk is so obvious that users joke about it, and dispensaries advertise certain strains as less likely to do so. But for people with psychotic disorders, paranoia can fuel extreme violence. A 2007 paper in the Medical Journal of Australia looked at 88 defendants who had committed homicide during psychotic episodes. It found that most of the killers believed they were in danger from the victim, and almost two-thirds reported misusing cannabis—more than alcohol and amphetamines combined.

The link between marijuana and violence doesn’t appear limited to people with pre-existing psychosis. Researchers have studied alcohol and violence for generations, proving that alcohol is a risk factor for domestic abuse, assault and even murder. Far less work has been done on marijuana, in part because advocates have stigmatized anyone who raises the issue. Still, there are studies showing that marijuana use is a significant risk factor for violence.

A 2012 paper in the Journal of Interpersonal Violence, examining a federal survey of more than 9,000 adolescents, found that marijuana use was associated with a doubling of domestic violence in the U.S. A 2017 paper in the journal Social Psychiatry and Psychiatric Epidemiology, examining drivers of violence among 6,000 British and Chinese men, found that drug use was linked to a fivefold increase in violence, and the drug used was nearly always cannabis.

Before states legalized recreational cannabis, advocates predicted that legalization would let police focus on hardened criminals rather than on marijuana smokers and thus reduce violent crime. Some advocates even claim that legalization has reduced violent crime: In a 2017 speech calling for federal legalization, Sen. Cory Booker (D., N.J.) said that “these states are seeing decreases in violent crime.”

But Mr. Booker is wrong. The first four states to legalize marijuana for recreational use were Colorado and Washington in 2014 and Alaska and Oregon in 2015. Combined, those four states had about 450 murders and 30,300 aggravated assaults in 2013. In 2017, they had almost 620 murders and 38,000 aggravated assaults—an increase far greater than the national average.

Knowing exactly how much of that increase is related to cannabis is impossible without researching every crime. But for centuries, people all over the world have understood that cannabis causes mental illness and violence—just as they’ve known that opiates cause addiction and overdose. Hard data on the relationship between marijuana and madness dates back 150 years, to British asylum registers in India.

Yet 20 years ago, the U.S. moved to encourage wider use of cannabis and opiates. In both cases, we decided we could outsmart these drugs—enjoying their benefits without their costs. And in both cases, we were wrong. Opiates are riskier than cannabis, and the overdose deaths they cause are a more imminent crisis, so public and government attention have focused on them. Soon, the mental illness and violence that follow cannabis use also may be too widespread to ignore.

—Mr. Berenson is a former New York Times reporter and the author of 12 novels. This essay is adapted from his new book, “Tell Your Children: The Truth About Marijuana, Mental Illness and Violence,” which will be published by Free Press on Jan. 8.

The Rosenthal Report - January 2019

Rosenthal Reports

2018: THE YEAR IN REVIEW

At the start of 2018 there was little hope that the opioid epidemic could be brought under control. A record 72,000 Americans had died from drug overdose the previous year, and legislation aimed at curbing the crisis was stalled in Congress. Yet by year’s end the number of fatalities appeared to be leveling off in a few states and cities that had introduced comprehensive prevention and treatment initiatives. One dramatic success story was Dayton, Ohio, which reduced by more than half the rate of overdose deaths. The beleaguered city, once the epicenter of the opioid epidemic, implemented a program that included expanding long-term treatment options, establishing a community support network and utilizing peer-based counseling. All of these approaches are components of the Rosenthal Center’s anti-drug strategy.

The news is certainly encouraging, but we must build on this first sign of progress with an infusion of new funding. And by that I mean significantly more than the $8 billion over the next 5 years included in the opioid bill signed in October by President Trump. It will also require strong leadership on a national level that has so far been lacking. And we must learn from Dayton and other successful programs in Rhode Island, Vermont and Virginia. Currently only one in five Americans in need of treatment for drug abuse receives care, a tragic situation when, as a nation, we have the resources to ensure that every individual struggling with addiction could have access to effective treatment.

During the year, the Center continued to make its voice heard on a range of addiction issues. We responded to the renewed debate over safe injection sites – where addicts use drugs in a supervised setting – proposing alternative facilities that would instead transition addicts to treatment. I worked with a forward-thinking Indiana company, Belden, to design an innovative, corporate-sponsored treatment program for job candidates who had failed a drug test but were willing to enter treatment. And with methamphetamine use resurgent, I made the case in an opinion piece for The Hill that it’s time to shift the focus of national drug policy to the substance abusers – rather than the ever-changing substance of the moment.

A highly disturbing feature of the past year was the acceleration of the movement to legalize and commercialize marijuana. The pot lobby wooed politicians and the public, promoting the fiction that marijuana is totally benign despite strong scientific evidence indicating otherwise. New pot products flooded the market with dubious medical claims. And companies including Coca-Cola and the tobacco giant Altria eyed marijuana startups. Amid this frenzy, I proposed a two-year moratorium on legalization to study the drug’s impact on health and social behavior in legalized states as well as in Canada. It’s too late now to stop legalization. But a brief pause would give us time to assess and evaluate how to regulate the soon-to-boom marijuana industry and better protect such vulnerable groups as teenagers.

We approach 2019 with a sense of guarded optimism for further evidence of a slowing opioid epidemic if the appropriate policies, funding and leadership are provided. Our research will concentrate on the needs of vulnerable adolescents and other overlooked population groups. We will continue to voice concerns about Big Pot and the risks posed by an uncontrolled marijuana market. As always, the Center will advocate thoughtful solutions to challenging addiction issues, always putting the individual first and supporting policies that help people achieve rewarding lives without drugs.

The Hill: It's time to rethink our national drug policy

The Rosenthal Report - December 2018

Rosenthal Reports

DAYTON REVERSES SOARING OVERDOSE DEATH RATE

A comprehensive program to contain the opioid epidemic in Dayton, Ohio has reduced by more than half the rate of overdose deaths, a remarkable turnaround for a city once considered the epicenter of the nationwide crisis. This former industrial hub, beset by high unemployment and poverty, has struggled for years to control the growing number of overdose fatalities. This year, with the new city- and county-backed effort in place, there were 250 overdose deaths through November 30th compared with 548 the year before.

The strategy features many ideas endorsed by the Rosenthal Center and should be considered a model for other municipalities. These include expanded access to a wide range of drug treatments such as both long-term residential and medically-assisted programs; peer-based counseling; closer cooperation between law enforcement and healthcare professionals; and a robust community support network for those in recovery.

Key to Dayton’s success was Ohio’s $1 billion Medicaid expansion under Governor John Kasich. While some critics contend that expansion under the Affordable Care Act exacerbates the opioid crisis because treatment sometimes involves opioid-based medications, it has in fact given 700,000 low-income adults in Ohio access to free addiction and mental health treatment. In turn, providers had the means to open a dozen treatment centers in a city with a poverty rate of 35 percent.

City officials added harm reduction measures and a robust recovery support system to the plan, and also adapted practices to meet specific local needs. For example, every police officer in Dayton carries a high dose version of the overdose reversal drug Naloxone to counteract the stronger opioids such as fentanyl that the city’s overdose victims were using. Peer counselors - former addicts who have gone through specialized training – make sure anyone who recently overdosed still receives services. While other cities are closing needle exchanges, believing they encourage drug use, two such facilities operate in Dayton but with the specific goal of signing up substance abusers for Medicaid and addiction treatment.

The promising outcomes in Dayton, detailed in a New York Times article, reflect a broadening trend across the country in which drug-related deaths are slowing in some cities and states that have implemented innovative programs. We’re not out of the woods yet, however. More than 70,000 Americans died last year from drug overdose, with two-thirds of those fatalities linked to opioids. And as opioid overdoses declined in Dayton, cocaine and methamphetamine use increased.

Still, Dayton is doing an exemplary job under Mayor Nan Whaley and police chief Richard Biehl. Their strategy brings together a strong civic commitment and significant financial resources. It deploys evidence-based strategies as part of a continuum of care that takes place on the streets, in treatment facilities, and in church basements that provide space for Narcotics Anonymous meetings. Once written off as hopeless, Dayton is showing the rest of the country what an effective anti-opioid strategy can accomplish.

VERMONT EASES ACCESS TO WITHDRAWAL MEDICATIONS

In the August Report, the Rosenthal Center proposed a new approach to the controversial issue of safe injection sites. I suggested that such facilities – where addicts can shoot up under supervised conditions – should instead be venues that move addicts into treatment. Dayton, as outlined above, is moving in that direction at needle exchanges that supply addicts with clean syringes.

Now Vermont is tweaking the concept by offering addiction treatment – including the withdrawal medication buprenorphine – on site at a needle exchange in Burlington, as well as in the emergency room of the University of Vermont Medical Center. The idea is to keep addicts off drugs by immediately administering withdrawal meds, to bridge the time until a treatment plan can be put in place. It’s a worthy idea for a trial project, considering how difficult it can be to obtain these meds (doctors must be certified to prescribe them) and how long it can take to find a treatment bed. The goal, in Dayton and Vermont, is to design a seamless transition for substance abusers to enter recovery.

5th December 2018

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Dayton's Successful Strategies to Address Opioids

Other

30th November 2018

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The Rosenthal Report - November 2018

Rosenthal Reports

IMPOSE A MORATORIUM ON MARIJUANA LEGALIZATION

The Rosenthal Center proposes a two-year moratorium on the legalization of marijuana to study the drug’s impact on health and social behavior in legalized states. Over the past few years, the drive to legalization – led by the pot lobby, cannabis companies and politicians recently converted to the cause - has created a seemingly unstoppable rush to commercialization. This has raised concerns about shifting consumption patterns, the toxicity of new pot products, and market regulation for both medical and recreational marijuana. As legalization accelerates – voters in four states including conservative Utah will decide on marijuana ballot initiatives in the midterms – it is time to pause. A two-year moratorium will provide ample time to accomplish the following: review evidence from states where pot has been legalized as well as in Canada, which took the step last month; evaluate current studies that show marijuana is far from a benign substance; and establish an appropriate framework to control the drug’s use and sale in the future.

I am most concerned about teenagers having easier access to today’s much more powerful marijuana. Adolescents are highly susceptible to the slick packaging and rosy (if dubious) health benefits ascribed to these new pot products, including those laced with CBD. This non-psychoactive component of pot is said to alleviate everything from aching joints to anxiety. There is, in fact, only one drug derived from the cannabis plant approved by the FDA (for epilepsy), and only anecdotal evidence suggests that pot can relieve nausea and help people with symptoms of PTSD, among many other unsubstantiated claims.

A two-year moratorium isn’t likely to stop the runaway train of legalization, as 62 percent of Americans favor it and 94 percent support medical marijuana. But it will allow time to better assess and evaluate the potential risks of pot, and put in place regulations and restrictions to control the rapid commercialization and widespread use of the drug.

DRUG OVERDOSES DEATHS ARE DOWN, BUT WE’RE NOT OUT OF THE WOODS YET

Preliminary tracking data from the Centers for Disease Control indicate a 2.8 percent drop in overdose fatalities in the 12-month period ending in March 2018, providing a glimmer of hope that the opioid crisis might be ebbing. Wider use of overdose reversal drugs and prevention and treatment initiatives in such states as Vermont, Rhode Island and Massachusetts – all of which registered declines in overdose deaths – are probably responsible for the slight decrease. But it’s not clear yet whether this is a blip or a sustainable trend. Despite the overall drop, deaths linked to the synthetic opioid fentantyl as well as methamphetamines are still rising. And even if the current decline in overdose rate continues for the rest of the year, an estimated 70,000 people will die in 2018 compared to more than 72,000 in 2017. That remains a tragic and unacceptable toll.

5th November 2018

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Drug addicts need a gateway to treatment – not “safe spaces” to get high

The Rosenthal Report - October 2018

Rosenthal Reports

New Opioid Legislation Unlikely to Slow Drug Epidemic

Long-awaited bill lacks bold strategy and boost in federal spending

Opioid legislation approved last month by Congress is a wasted opportunity. The bipartisan bill, hammered out over the past year, merely tinkers at the edges of the epidemic instead of setting out a coordinated national strategy. Most glaringly, it fails to allocate significant new long-term funding to expand access to drug treatment – our most effective means of curbing a surge in overdose deaths across the country.

To win support on both sides of the aisle, Congress adopted a scattershot approach when drafting the Opioid Crisis Response Act of 2018. The bill includes a number of worthy initiatives supported by the Rosenthal Center, such as grants for addiction and pain treatment research, stricter law enforcement to halt the flow of illicit drugs like fentanyl, and easier ways for addicts to obtain withdrawal medications. But the legislation, enacted one year after President Trump declared a national health emergency, does not contain an overall plan or a suitable increase in federal dollars for states, cities and organizations on the frontline of the crisis.

Early estimates suggest the bill will cost between $5 billion and $8 billion to implement over five years. A more appropriate allocation would be in the range of $100 billion over the next decade, a proposal made by Senator Elizabeth Warren and Representative Elijah Cummings that never got off the ground.

If such funds were available, I would direct the money to expanding a wide range of treatment options and redressing the severe shortage of long-term residential beds for the most vulnerable addicts. We must also support innovative programs in prisons and in poorly served rural areas, and provide targeted treatment programs for neglected teenage drug users. We should, in addition, address the growing problem of workplace addiction that is exacerbating the nationwide labor shortage (see story below).

No doubt the opioid bill will make a good talking point for candidates in the coming midterm elections. They can boast about doing something about an epidemic that killed more than 72,000 Americans last year. In fact, a Wall Street Journal analysis found that, so far in 2018, campaign ads containing opioid messaging in congressional and gubernatorial races have aired more than 50,000 times across 25 states, including West Virginia and Ohio, states with closely contested races and increasing numbers of overdose fatalities.

Such messages might swing an election. But they won’t guarantee affordable and effective addiction treatment for those suffering and dying from substance abuse. Helping these people must now become a national priority.

INNOVATIVE CORPORATE-BACKED DRUG TREATMENT PROGRAM SHOWS PROGRESS

The drug treatment initiative I helped design a year ago for Belden, an international manufacturing corporation, is yielding positive results. During a recent follow up visit to the company’s factory in Richmond, Indiana, I learned that a number of employees who successfully completed the Pathways to employment program are now operating machinery on the factory floor. Pathways is unique because instead of turning away job applicants who fail a drug test, it promises permanent jobs to those who commit to drug treatment and random drug testing.

The U.S. Chamber of Commerce has praised the program. When I was there a delegation of federal officials came to see the program, including Surgeon General Dr. Jerome Adams, Secretary of Labor Alexander Acosta, the president's senior counselor, Kellyanne Conway, and Vice President Pence's wife, Karen Pence and the former first lady of Indiana. They were excited by the potential of the model and the early positive results.

Corporate America can’t single-handedly solve this drug crisis. But for the growing number of companies like Belden that face similar challenges finding drug-free workers, Pathways to Employment serves as a model that addresses the labor shortage, fights addiction and supports communities.

2nd October 2018

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The Hill: How Private Sector Can Fight Opioid Epidemic

The Rosenthal Report - September 2018

Rosenthal Reports

In the September issue of the Rosenthal Report, we examine data confirming 2017 as the worst year yet for the opioid epidemic, explore the looming legal showdown over safe injection sites, and urge caution as the legalization and commercialization of marijuana accelerates.

Drug overdose deaths at record high

Latest data from the Centers for Disease Control confirm forecasts that 2017 would be the worst year yet for the opioid epidemic. According to nearly complete reporting from the states, more than 72,000 Americans died from drug overdose, an increase of 9.5 percent from 2016, and the highest death toll ever recorded. About two-thirds of those deaths are linked to opiods, especially the powerful synthetic opioid fentanyl that the CDC says is replacing less potent heroin and prescription opioid pills as the biggest killer.

Overdose deaths rose sharply in some states already hit hard by the epidemic: 27 percent in New Jersey and 17 percent in Ohio as well as Indiana and West Virginia. But several states that introduced comprehensive public health campaigns and increased access to addiction treatment saw overdose deaths fall: 7.1 percent in Rhode Island, 5.8 percent in Vermont, and 1.1 percent in Massachusetts.

The epidemic continues to spread almost one year after President Trump declared a national health emergency - and then told Congress to figure out the details. While the House has passed dozens of bills, the Senate might not wrap up its version until the end of the year. In any event, there’s nothing in the legislation that would fundamentally change the current approach to treating addiction or allocate the massive funding needed to address a crisis that kills nearly 200 people a day. As some states have shown, there are effective strategies to bring this epidemic under control, but these would require leadership on a national level that is sorely lacking.

Safe injection sites v. the Department of Justice

A showdown is looming between cities that want to open safe injection sites for drug addicts and the Department of Justice, which says such facilities are not only illegal but also fail to curb drug use and drug-related crime. Currently, San Francisco is edging closer to opening what would be the nation’s first safe site, where substance abusers can shoot up under supervised conditions and obtain information about drug treatment. The mayors of New York, Philadelphia and Seattle are also planning safe sites, and remain defiant in the face of DOJ opposition. In August, Deputy Attorney General Rod Rosenstein published an op ed article in the New York Times warning he would take “swift and aggressive action” action against safe sites. As the rhetoric heats up, the Rosenthal Center proposes an alternative to the safe site concept: treatment transition centers that, rather than facilitating surrender to drugs, encourages addicts to enter life-changing treatment (see August Rosenthal Report.)

Mixed messages about marijuana

Cannabis-infused edibles are on the menu at many restaurants and pot-laced body wraps can be found at spas. The drug is touted on Wall Street as an investment opportunity, while Big Tobacco and Big Booze eye stakes in pot production. But as legalization and commercialization of the drug continues, there are also warnings about pot’s potential danger. A recent study found that low levels of THC, the psychoactive component of marijuana, linger in breast milk for up to six days after nursing mothers use the drug. In Colorado, drivers in fatal crashes increasingly test positive for marijuana. And a growing number of Americans report near-constant cannabis use, writes Annie Lowrey in her Atlantic column, “America’s Invisible Pot Addicts.” As a result, cannabis-use disorder is becoming far more common than many realize, Lowrey says, due in part to easier access and stronger pot.

With marijuana marketed as a lifestyle product and panacea for many ills, including depression and opioid addiction, we agree with Lowrey’s call for “reintroducing reasonable skepticism” into the national conversation. Caution is critical as commercial interests attempt to drive the legalization and regulatory debate.

To Combat The Opioid Epidemic, Focus On The Forgotten Addict

The Rosenthal Report - August 2018

Rosenthal Reports

In the August issue of the Rosenthal Report, we look at renewed debate over safe injection sites for heroin and other opioid users and propose an experimental model for facilities that would provide a clear route into treatment rather than assistance for safe injection.

The Rosenthal Center proposes research to evaluate whether injection facilities can be designed to provide the essential bridge to treatment. Our model, Transition Treatment Centers, would include staffing by medical personnel and peer-based counselors, and be affiliated with a treatment network. They would offer a range of services, including medications and special assistance for safe injection. But most importantly, the Centers would provide an introduction to treatment on site, require participation by facility users, and limit the use of program facilities to no more than 60 days, in anticipation of a seamless passage to longer-term care by then. There are no easy solutions to the growing opioid epidemic. But sites that facilitate entry into life changing drug treatment - and not a surrender to a life of drug use – might prove to be a useful element of a comprehensive anti-opioid strategy.

Drug overdose deaths continue to climb in many U.S. cities, prompting politicians and policymakers in New York, Seattle, Philadelphia, San Francisco and elsewhere to advocate for the nation’s first safe injection sites. While many cities currently have needle exchange programs, where users receive a clean syringe, safe injection sites would allow addicts to shoot up under the supervision of health-care workers. Staff would not provide illegal drugs, but would administer overdose reversal medication and provide counseling and information about drug treatment options and programs.

Some 100 safe injection sites exist in Europe, Australia and Canada, but such facilities face legal and policy challenges in the U.S. Technically, they are illegal under federal law and there is ongoing controversy over their effectiveness. Supporters say supervised sites can prevent overdose deaths, reduce the transmission of HIV and hepatitis, and increase the number of people in treatment. But critics argue that by providing a safe space the sites encourage, rather than hinder, drug use and therefore perpetuate addiction. Moreover, they say that most addicts using the sites would be unlikely to enter treatment programs voluntarily.

In New York City, the plan recently unveiled by Mayor Bill de Blasio envisions four sites, called Overdose Prevention Centers, as pilot projects run by nonprofit groups and staffed by social workers and other trained professionals to administer medications and counsel addicts on treatment. Community outreach would precede the launch, encouraging public support for safe injections sites, which are generally opposed by their neighbors. A nationwide study in the June issue of Preventive Medicine found that among those surveyed only 29 percent supported legalized injection sites in their communities.

Some preliminary studies suggest that safe injections sites can reduce overdose deaths and increase the number of addicts in treatment. A report submitted by the New York City Health department with the mayor’s proposal estimated the four planned sites might prevent up to 130 overdose deaths a year (New York City had a record 1,441 last year). But more definitive, long-term studies are lacking, especially in the unique U.S. urban settings where sites are now being considered.

News briefs cover speculation about a possible Congressional slowdown on opioid legislation and an all too rosy view of pot.

PLAYING POLITICS WHILE PEOPLE ARE DYING

With nearly 200 Americans dying every day from drug overdose, bi-partisan legislation to combat the opioid epidemic should be winging its way through Congress. But so far only the House has passed bills; the Senate is dragging its feet. The Washington Post speculates that the purported Republican-led slowdown might be due to election year politics. Approving legislation before the upcoming midterm elections would play well for vulnerable incumbent Democratic senators in states hit hardest by the drug crisis, including West Virginia, Indiana and Missouri. While the initiatives and funding in the proposed bills don’t go far enough to fight the epidemic, politics should not stand in the way of providing more help to those suffering and dying from substance abuse.

MEMO TO AMERICANS: POT IS NOT A PANACEA

Americans have a much rosier view of marijuana than is backed up by science, according to a survey of more than 16,000 adults by the University of California, San Francisco. The study found that 36.9 percent of respondents believe that edible pot could prevent health problems, and 27.6 percent thought that driving under the influence of marijuana was safer than driving while drunk. The lead author of the study told Reuters that these relatively benign views of weed could be attributed to marijuana legalization – conflating legality and safety – as well as pot not being linked to the overdose deaths of the opioid epidemic.

1st August 2018

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The Rosenthal Report - July 2018

Rosenthal Reports

In the July issue of the Rosenthal Report, we examine new data showing an apparent increase in drug overdose deaths in 2017 as the opioid epidemic continues to spread across country, and outline the essential components of a nationwide strategy to tackle the crisis. In news briefs, marijuana legalization rolls on and Big Tobacco bets on Big Pot.

2017 might become the deadliest year yet of the national opioid epidemic.

Provisional data from the Centers for Disease Control through the 12-month period ending November 30, 2017 indicate that about 200 Americans are dying every day from drug overdose, up from roughly 175 per day in 2016. If the trend continues through the end of the year, the finalized figures would bring last year’s annual death toll to nearly 73,000, the CDC predicts, an increase of 13.2 percent over the previous year. It is a grim reminder of the epidemic’s tenacious grip on the country – as well as, hopefully, a call to action to address this crisis.

The data shows worrisome trends in some states. Overdose deaths spiked 36 percent in Nebraska, which had previously reported a low rate, while New Jersey, a state that has implemented a robust anti-opioid strategy under former governor Chris Christie, saw an increase of 36.8 percent. The death rate rose 27 percent in Indiana and in Pennsylvania (there were declines in Utah and Montana, at 15.1 percent and 7.2 percent, respectively.)

As noted by the Rosenthal Report, a number of cities and states have introduced innovative initiatives to confront the crisis, such as Rhode Island’s prison treatment program. But we’re failing on the national level. President Trump declared a national public health emergency last October. His opioid commission issued a report with nearly 60 policy recommendations. Then the president left details to be worked out by Congress. Last month, the House debated more than 50 bills and eventually consolidated and approved bipartisan legislation that includes dozens of proposals. This measure now goes to the Senate.

Unfortunately, the House bill is a grab bag of narrowly tailored items that, on their own, fall short of the full bore initiative we desperately need. The bill calls for more research into non-addictive pain medications; permits nurse practitioners and physician assistants to prescribe addiction withdrawal medications; and provides grants to help law enforcement test for the presence of fentanyl. While there is some good policy among its many provisions, they do not constitute a coordinated nationwide strategy nor do they significantly expand access to addiction treatment.

What’s more, there’s no additional funding beyond the $6 billion already set out in the $1.3 trillion budget deal approved in March. As the Senate considers the opioid legislation, these are the issues that must be addressed:

LEADERSHIP

The federal government, perhaps through ONDCP (the office of the “drug czar”), should assume the role of national coordinator, overseeing development of state and city programs and funding across the country to ensure we are pursuing a comprehensive strategy, meeting goals and targets and exploring innovative approaches.

TREATMENT

Because only a fraction of those suffering from addiction receive any kind of treatment, we need to expand access to a broad range of treatment services including medication-assisted treatment, (MAT), which combines medication with behavioral therapy, along with outpatient and residential programs that employ peer-based counseling and long-term residential treatment for the most vulnerable patients.

FUNDING

Instead of the $6 billion in the budget deal for 2018 and 2019, what is needed is something closer to the proposal of Senator Warren of Massachusetts and Representative Cummings of Maryland for $100 billion over the next decade to put the country on a war footing and ensure sustained support for efforts that combat the opioid crisis, using as a model HIV/AIDS legislation that boosted money to cities, states and the hardest-hit communities.

Sadly, we lost ground in 2017. More people died from overdoses and thousands more continued to struggle with addiction, unable to receive treatment that could put them on the road to recovery. This epidemic could be effectively reversed; we know what to do. What’s missing is the leadership and commitment to a coordinated, well-funded national program focused on treatment to bring it under control.

NEWS BRIEFS

MARIJUANA LEGALIZATION ROLLS ON

Canada’s parliament approved a long-awaited bill to legalize weed, and across the border in Vermont the state legislature approved the sale of recreational pot – the ninth U.S. state to do so. Meanwhile, New York City mayor Bill de Blasio decriminalized pot smoking in public. It can be difficult, however, to get a clear picture of public sentiment as laws change and politicians shift positions. For example, a recent poll of New Yorkers by Emerson College for the organization Smart Approaches to Marijuana, found that only 22 percent and 24 percent of Latinos and African Americans, respectively, support legalization. The survey also found that 76 percent of New Yorkers do not support pot advertising and 58 percent do not want marijuana stores in their neighborhoods.

BIG TOBACCO BETS ON BIG POT

The British-based tobacco giant Imperial Brands has taken a stake in the U.K. startup Oxford Cannabinoid Technologies to research medical uses of cannabis, the Wall Street Journal reported. Analysts described the $13.1 million investment as “the most significant among the global tobacco players in the cannabis industry to date.” Imperial, which owns the Winston cigarette brand, said the company’s interest is limited to medical uses of marijuana.

9th July 2018

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By Investing in Rehab for Job Applicants, an Indiana Company Hopes to Keep its Factory Humming - and Workers Drug-Free

The Rosenthal Report - June 2018

Rosenthal Reports

To fight the opioid epidemic, cities and states tweak the standard toolkit of addiction treatment – with promising results

In the June issue of the Rosenthal Report, we explore innovative approaches to the use of medication-assisted treatment in Baltimore and Virginia, as well as Rhode Island’s pioneering prison treatment program that has significantly reduced overdose deaths. In news briefs, we look at a spike in overdose deaths among black drug users in Massachusetts, and the movement to decriminalize magic mushrooms.

Medication-assisted treatment, MAT, is fast becoming the core strategy in our nationwide anti-opioid battle. It is endorsed by the Rosenthal Center as an effective addiction treatment when combined with behavioral therapy as well as with peer-based counseling and long-term residential treatment for the most vulnerable patients. In inner cities and Rust Belt towns, as well as correctional facilities, where this epidemic is so relentless and widespread, some policymakers are now implementing broad based services systems for opioid users anchored by MAT programs.

Baltimore, for example, a city that recorded nearly 700 overdose deaths in 2016 compared to 167 in 2011, has launched a “levels of care” treatment program centered in hospital emergency rooms. Nearly all of the city’s 11 ERs now provide MAT “on demand” to addicts, in a program that includes overdose reversal drugs, drug screening, peer recovery specialists, support services and referrals to longer-term treatment. This “wrap-around” model integrates treatment into Baltimore’s existing healthcare system, and is designed to ensure that no patient “slips through the cracks,” according to Baltimore mayor Catherine E. Pugh.

Virginia is getting more patients into MAT through Medicaid. Although the state only this week approved Medicaid expansion under the Affordable Care Act, it initiated a program in 2017 called Addiction and Recovery Treatment Services (ARTS). This provides financial incentives through Medicaid, such as higher reimbursement rates to addiction treatment providers, rewarding them for expanding services. Initial results are encouraging: in the first nine months of the program, opioid prescriptions and emergency room visits were down, and more than 16,000 Medicaid members received treatment for addiction, a two-thirds increase over the previous year.

Rhode Island’s prison program, which began in 2016, is also attracting attention. It offers a full range of MAT services – screening for all inmates, medications and peer counseling – and is the first such program for correctional facilities, which do not generally provide comprehensive treatment. Equally important, it ensures critical follow-up care so that former inmates continue to receive medications and therapy during the difficult post-release period, when addicts are most susceptible to relapse. One year into the program, the number of overdose deaths among recently released prisoners in Rhode Island plunged 61 percent.

The Rosenthal Center applauds such innovations. Tweaking the basic tenets of the MAT model to meet specific patient needs, budgets and healthcare delivery systems can substantially increase its effectiveness. Moreover, by mobilizing the national resource of persons in recovery – as these programs do – it is possible to vastly expand treatment strength and capacity. We must keep experimenting and moving forward, as there’s no one-size-fits-all solution to this deadly crisis.

BRIEFS:

Black overdose deaths in Massachusetts defy statewide decline

Drug overdose deaths in Massachusetts fell in 2017, but not for every demographic: the death rate among whites dropped 13 percent and among Latinos 4 percent, but it surged 26 percent for blacks, a disturbing trend that mirrors a nationwide pattern in urban black populations. Researchers suspect the spike is due in part to increased use of cocaine that is laced (either intentionally or not) with the powerful synthetic opioid fentanyl.

Magic mushrooms on the menu

Micro-dosing LSD and other hallucinogens is a thing now, receiving widespread coverage in the New York Timesand a new book by acclaimed author Michael Pollan that explores “the new science of psychedelics.” But as these drugs are still illegal, advocates in Denver are trying to mount ballot initiatives to do away with felony charges for possession of magic mushrooms, citing studies showing purported mental health – as well as spiritual - benefits. Activists are using the playbook from the fight to legalize recreational marijuana in Colorado, which means they just might succeed.

4th June 2018

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CNN: This company needs workers so badly it's putting them through drug rehab

NY Times: Letter to the Editor

The Rosenthal Report - May 2018

Rosenthal Reports

In this month’s Rosenthal Report, we examine a record decline in opioid prescriptions and an increase in the use of addiction medications, and explain what this means in the fight against the opioid epidemic. In news briefs: Rhode Island reduces overdose deaths among recently released prisoners; and politicians recalibrate their positions on marijuana legalization.

Policies on Opioid Prescribing and Addiction Medications Yield Promising Results, But Must be Part of a Comprehensive Strategy

Efforts to limit the volume of opioid prescriptions and increase the use of addiction treatment medications are having an impact. According to newly released data, the volume of clinically prescribed opioids declined 10 percent in 2017. This was the steepest fall in 25 years, and included a16.1 percent reduction in high-dose prescriptions. Meanwhile, new monthly prescriptions for three FDA-approved addiction drugs that relieve withdrawal symptoms and drug cravings - methadone, naltrexone and buprenorphine – nearly doubled to 82,000 over the past two years.

The new data illustrates the effectiveness of two critical strategies: more aggressive monitoring mechanisms and stricter clinical guidelines to limit opioid prescriptions, and expanded access to medication-assisted treatment (MAT) programs that combine appropriate addiction medications with counseling and behavioral therapy.

These results are encouraging, but must be considered in the broader context of a deeply entrenched national epidemic. For example, the nation’s death toll from the drug crisis continues to rise. While 15 states lowered their rate of overdose fatalities, there were double-digit spikes in the other 35. This was largely due to the influx of the powerful synthetic opioid fentanyl, which is mixed with other drugs and is now the leading cause of overdose deaths, outpacing for the first time prescription opioids.

Any reduction in opioid prescriptions, which peaked in 2011, is welcome. Yet even with the latest decline opioids are still massively overprescribed. As the New York Times pointed out, the nation’s annual level of morphine prescriptions now totals 171 billion milligrams - enough for every American adult to have 52 pills. After clawing our back to 2006 prescribing levels, we must continue to reduce the availability of prescription painkillers while ensuring that those with legitimate needs for these drugs have access to their medications.

Expanding treatment and getting more addicts who need it into MAT programs is critical to slowing the epidemic. However, the latest data does not indicate how many new addiction medication prescriptions are filled for MAT patients who are not receiving concurrent therapy. This would be simply swapping one drug for another without providing support for life change. There are also significant gaps in access to addiction medications: an estimated 60 percent of rural counties do not have one doctor authorized to prescribe buprenorphine, which requires a waiver from the Drug Enforcement Agency.

We are making strides to bring the opioid crisis under control. But success depends on accelerating the pace by implementing comprehensive, coordinated, and well-funded strategies. Last month, Senator Elizabeth Warren of Massachusetts and Rep. Elijah Cummings of Maryland introduced a bill calling for $100 billion in funding over the next decade to address the opioid epidemic. Modeled on successful HIV/AIDS legislation, the bill is a major funding boost from Congress’s current $6 billion annual budget proposal. With nearly 64,000 Americans dead in 2016 from drug overdoses, $200 billion would be a more appropriate commitment.

BRIEFS:

SMALL STATE, BIG RESULTS: Rhode Island slashed the overdose mortality rate among recently released prisoners by 61 percent, according to a study in JAMA Psychiatry. Credit goes to a new program offering all inmates screening and MAT treatment while in jails and prisons as well as at outpatient facilities post-incarceration, when, as the study noted, they are more likely to relapse.

SWITCHING SIDES: Former Republican House Speaker John Boehner, once a staunch opponent of marijuana legalization, has joined the advisory board of Acreage Holdings, a company that cultivates, processes and sells cannabis in 11 U.S. states. Explaining his new position, Boehner said his thinking had “evolved” after studying the criminal justice system and the needs of veterans to access the drug legally for disorders such as PTSD. Boehner joins the legalization bandwagon at a time when politicians from both parties are assessing voter sentiment on pot and recalibrating their positions accordingly, including New York Senator Chuck Schumer who now favors federal decriminalization of marijuana. Meanwhile, New York Governor Andrew Cuomo faces a spirited challenge for the gubernatorial nomination from actor Cynthia Nixon, who has made legalizing recreational pot a centerpiece of her campaign against the incumbent.

4th May 2018

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There Are No Easy Medical Solutions to the Opioid Crisis

The Rosenthal Report - April 2018

Rosenthal Reports

In this month’s report, we examine the administration’s highly controversial, get-tough strategy for the national opioid epidemic and look at new studies that raise questions about drugs routinely used for pain management and fighting opioid addiction. In news briefs: soaring nationwide consumption of cocaine and tranquilizers and New York City ups its anti-opioid budget.

President Trump unveiled his administration’s long-awaited anti-opioid strategy, but if anyone were expecting a balanced approach they would have been disappointed. The focus on law enforcement – harsher sentences for drug crimes, building a southern border wall, and the death penalty for drug dealers – not only ignores history (the failed “war on drugs” in the 80s) but also research proven addiction treatment solutions. In editorials, Trump’s get-tough solutions were roundly criticized as “alarming” (Houston Chronicle) as well as “preposterous” and “insane” (New York Times). The Rosenthal Center would add: troubling, even dangerous.

Executing drug dealers, as Iran and the Philippines do, won’t end the opioid epidemic or curtail drug consumption. A border wall won’t curb letter-sized shipments of deadly fentanyl from China, purchased over the dark web. A recent study by the Pew Charitable Trusts found “no statistically significant relationship” between state drug imprisonment rates and overall drug use, drug overdose deaths and drug arrests. The President may believe that such bluster plays well with his base, but it ignores the plight of millions of Americans struggling with substance abuse.

Law enforcement should be one element of a comprehensive strategy. But what is more important is the need for greater access to treatment – in particular, long-term residential treatment for the most vulnerable drug users. We also need more education, prevention and outreach programs. Everyone who requires help must be able to receive it (now only around 10 percent of those with substance abuse disorder receive treatment).

President Trump hinted at these priorities but failed to provide any details or specific proposals. Now it’s up to Congress to figure out what to do; dozens of bills are being discussed and there’s $6 billion in the budget. The Rosenthal Center supports boosting funding to expand treatment and establishing a secure funding pipeline to the states. Politico reported that many states have left untouched hundreds of millions of dollars from the 2016 21st Century Cures Act because of the lack of ongoing commitments, which make it difficult for them to start programs and hire a workforce. This money is being lost – and so then are lives.

New studies raise questions about both prescription opioid use and addiction medications

Opioids are still prescribed for pain management, while the standard drug arsenal for addiction medicine includes Naloxone to reverse overdoses and Suboxone to curb drug craving. But now, a slew of recent studies suggest that our assumptions about all of these drugs may need revising.

A JAMA report, for example, found that opioids are no more effective against common forms of chronic back pain or hip or knee arthritis than are over the counter painkillers such as acetaminophen. When it comes to Suboxone, John Hopkins University researchers found fully two thirds of the patients in their study, who received that drug in treatment, were filling prescriptions for opioid medications in the year after treatment and nearly half were doing so while still in treatment. As for Naloxone, a controversial report noted that the drug “led to more opioid-related emergency room visits and more opioid-related theft, with no reduction in opioid-related mortality.”

While such studies are important to our understanding of these drugs and the impact they have, we shouldn’t stop using them in clinical practice. As the national opioid epidemic evolves we must continually re-evaluate the necessity of drugs used to fight pain and the efficacy of adjunctive drugs used in addiction treatment. If anything, the Naloxone findings underscore the Rosenthal Center’s belief that reviving addicts from an overdose is only the first step to recovery. We must then provide immediate evaluation, assessment and comprehensive treatment options, and have the ability to use compassionate coercion, if needed, to compel addicts to start this process.

Briefs:

BIG APPLE BUDGET: New York City upped its anti-opioid spending by $22 million to a total of $60 million in 2018; the money will toward improving drug overdose response times by emergency workers and more programs to connect patients at public hospitals with substance abuse treatment.

COCAINE COMEBACK: After falling by 50 percent between 2006 and 2010, cocaine consumption and cocaine-related deaths have soared, especially among African-Americans, making the drug the nation’s Nr. 2 killer among illicit drugs.

AMERICA’S NEXT BIG DRUG PROBLEM: In the shadow of the opioid crisis, there have been dramatic increases in prescriptions for benzodiazepines - tranquilizers better known as Xanax, Valium and Klonopin – and quantities of the drugs taken by adults as well as teenagers have increased as well. While overdose deaths involving benzodiazepines are much fewer than opioids, the drugs are sometimes mixed with fentanyl for a stronger high, posing a heightened risk of overdose.

4th April 2018

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To End the Opioid Epidemic, We Must Expand Substance Abuse Treatment - Thrive Global

The Rosenthal Report - SPECIAL REPORT

Rosenthal Reports

Trump’s Troubling “Get-Tough” Opioid Strategy

President Trump unveiled his long-awaited anti-opioid strategy, but much of what he said was disappointing.

Instead of focusing on expanding treatment – especially long-term residential treatment for the most vulnerable addicts – the President proposed a “get-tough” law-enforcement approach as a way to end this national epidemic.

But harsher drug sentences, building a wall on the southern border and advocating the death penalty for certain drug-related crimes won’t stop the surge in drug overdoses.

We must be tough on crime, to be sure. But let’s also be tough (and thoughtful) on treatment. The urgent need is for greater access to treatment once an addict has been revived from an overdose and starts a drug regime to reduce cravings.

The president also mentioned advancing medication-assisted treatment (MAT), wider use of overdose-reversal drugs, reducing opioid prescriptions and helping vets and prisoners stay off drugs.

All good ideas – yet that requires more money. Congress has already allocated $6 billion in new funding to fight the epidemic. That’s not enough. We need to immediately double the block grants to the states to $3.8 billion annually over the next decade. Let the states take the lead so more troubled Americans get the treatment they desperately need.

21st March 2018

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For Many Drug Addicts, Compassionate Coercion May Be the Best Medicine - Thrive Global

The Rosenthal Report - March 2018

Rosenthal Reports

In this month’s Rosenthal Report, we present an in-depth look at the widespread use of marijuana wax, a highly potent marijuana product that has become popular among adolescents, and propose an action plan to increase awareness of this potentially dangerous drug. In news briefs, drug overdose deaths decline in some states but spike in others; the White House convenes an opioid summit; and the U.S. has a new drug czar.

Marijuana Wax Poses New Risks

The marijuana concentrate known as wax is a powerful and potentially dangerous drug, and its use today appears to be more widespread, especially among adolescents, than had been previously known. At a time when teen use of tobacco, alcohol and drugs has been in steady decline, the rapid spread of wax poses new risks for this vulnerable age group and underscores the need for more large-scale studies of the drug.

Marijuana wax, also called dabs, shatter or honey, is derived from marijuana leaf by dousing the ground buds with a solvent such as flammable butane to extract the tetrahydrocannabinol (THC), the psychoactive chemical component in cannabis. The yellowish, sticky substance that remains is wax. It is heated – sometimes with a blowtorch, or in an e-cigarette - and the vapor inhaled for a potent hit of between 60 percent and 90 percent concentrated THC, compared to between 10 percent and 20 percent from smoking plain marijuana leaf.

Disturbing trends

Interviews with wax users and clinicians suggest several disturbing trends. Wax can be purchased at medical marijuana dispensaries in states were it is legal. Young people underestimate the intense, often hallucinogenic high the drug delivers; instead, they view it more casually as an alternative to smoking leaf marijuana. Finally, there appears to be only limited awareness of the drug and its possible harmful effects among parents, addiction specialists and educators.

“Wax was uncommon a few years ago, but now kids are all over it as part of early experimental drug use,” says John Venza, vice president of adolescent services at Outreach, a nonprofit treatment provider for adolescents in New York City and Long Island. Chinling Chen, regional vice president of youth services at Phoenix House in California, says the drug wasn’t initially on their radar screen, but a recent survey of residents at the program’s Los Angeles facility indicated that wax is “widely available and many kids are well versed in its use.”

Increased wax use parallels medical marijuana legalization: the drug is part of the product line of THC-based concentrates, the fastest growing sector of the legal marijuana industry. In non-legal states, wax is manufactured with a do-it-yourself contraption - known as a dab rig - that can cause fires or personal injury (the city of Los Angeles considered banning “volatile cannabis manufacturing” but settled on restricting it to outside residential areas). Today, companies that sell medical marijuana produce wax in their own facilities and users can safely vape the product in e-cigarette devices, which are very popular with teenagers.

Seeking a ”really strong high”

Jade, a 16-year old high school student, currently in drug treatment, could be regarded as a typical teenage wax user. Jade [not her real name] told us that she heard about the drug from friends – “all of them are using it,” she says. Jade would buy wax herself in a dispensary, despite age restrictions, or get someone of age to buy it for her. She kept a portable vape pen handy, and because wax is odorless and smokeless, she could inhale the drug undetected in her bedroom or in a school bathroom with friends to get a “really strong high.” Another teenage user described it as a “numbing body high.” Both said they would switch between wax and marijuana leaf or sometimes mix the two.

Preliminary studies have identified potential risks associated with wax. A 2017 Portland State University report found that wax contained cancerous toxins such as benzene. A 2014 study in Addictive Behaviors concluded that a majority of users preferred wax to smoking traditional cannabis due to its potency, and that extremely high THC levels may lead to higher tolerance - suggesting a more rapid progression to chronic marijuana dependency. However, these studies have been limited in scope and therefore lack critical evidence and data.

What we can do

As the use of wax proliferates, we must begin large-scale longitudinal studies to answer questions about its potency and toxicology as well as the long-term impact on users – especially teenagers. At the same time, we should initiate an extensive public education and awareness campaign to ensure that users, parents and educators are alert to wax’s dangers and that clinicians ask questions about wax and other powerful THC products when they evaluate patients.

BRIEFS

Overdose deaths decline in some states, spike in others

Provisional data from the Centers for Disease Control suggests that drug overdose deaths declined in 14 states in the 12-month period ending July 2017, an encouraging sign that efforts to slow the opioid epidemic might be working. But in five states - Delaware, Florida, New Jersey, Ohio and Pennsylvania – overdose deaths rose by more than 30 percent, most likely due to the increased presence of the powerful synthetic opioid fentanyl.

White House Opioid Summit

At a special White House opioid summit, cabinet secretaries, policymakers and members of the public affected by the opioid crisis discussed ways to combat the epidemic, from stricter law enforcement to more education, prevention and treatment. Health and Human Services secretary Alex Azar focused on expanding medication-assisted treatment (MAT) and speeding up Medicaid waivers to allow more facilities to provide substance abuse treatment. For his part, President Trump floated the idea of imposing the death penalty for drug dealing, suggesting that countries with capital punishment for this crime

have a better record that the U.S. in combating drug abuse. He did not outline any specific proposals to combat the epidemic as Congress considers how to appropriate $6 billion for the crisis allocated in its recent bipartisan budget deal.

Meet the nation’s new “drug czar”

Making his first public appearance at the summit was the nation’s new acting drug czar James Carroll, the White House deputy chief of staff who was nominated by President Trump to fill a post that has been vacant since December 2017. The position, officially known as Director of the Office of National Drug Control Policy, helps coordinate U.S. drug policy.

2nd March 2018

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The Rosenthal Report - Special Report

The recently approved two-year Congressional budget deal includes $6 billion to fight the opioid epidemic, a desperately needed influx of funding for this national drug crisis. According to the plan, $3 billion would be available in 2018 and the remainder in 2019, while keeping intact the existing $1 billion in funding from the 21st Century Cures Act that covered 2017 and 2018. What’s missing from the Congressional deal, however, is how the new money will be spent. Senate Majority leader Mitch McConnell has said the $6 billion will go toward “new grants, prevention programs and law enforcement in vulnerable communities across the country,” without offering any specific details.

By any measure, the additional $6 billion is still a drop in the bucket considering the scope of the crisis: drug overdose deaths for 2017 are expected to exceed the nearly 64,000 who died in 2016. President Trump’s 2019 budget proposal, released a few days after the Congressional agreement, proposed $13 billion for the opioid crisis, with much of that funding being diverted from the office of the White House “drug czar” to the Department for Health and Human Services. As this is highly unlikely to win Congressional approval, the Rosenthal Center has compiled a wish list of priorities for the $6 billion commitment:

Ensure that all the money allocated by Congress goes toward education, prevention and treatment rather than law enforcement, as the “tough on crime” approach favored by Attorney General Jeff Sessions has little or no impact on drug use.

$3.8 billion in new money to double the size of the current federal Substance Abuse Prevention and Treatment Block Grants to the states with the entire amount set aside for prevention, treatment and recovery services. Such grants are quick and easy to implement, and would give the states on the front line of the crisis a secure pipeline for programs already underway, including those that are starting to reduce the overdose death rate.

initiatives focused on education, prevention and treatment programs focused on the highly vulnerable adolescent age group, in order to prevent the next generation of adult addicts.

establishing a new workforce development program in the addiction services sector to alleviate the scarcity and rapid turnover of personnel, including education loan forgiveness if grantees serve in addiction facilities in high need areas.

14th February 2018

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The Rosenthal Report - February 2018

Rosenthal Reports

THE TRUMP ADMINISTRATION IS AWOL ON THE OPIOID EPIDEMIC

No new funding proposals forthcoming in the State of the Union

National health emergency renewed without clear strategy or leadership

The Rosenthal Center proposes a long-term action plan to end the epidemic

At a time when 175 Americans die every day from a drug overdose, it was discouraging that President Trump’s State of the Union on January 30th touched only briefly on the opioid crisis and failed to include any proposal for additional funding to fight this national epidemic. The president said he was committed to helping get treatment “for those who have been so terribly hurt” by addiction, but offered neither a clear strategy nor more money. Instead, he signaled approval of the law-and-order approach being pursued by attorney General Jeff Sessions, vowing to “get much tougher on drug dealers and pushers if we are going to succeed in stopping this scourge.”

Trump’s declaration of an opioid public health emergency in October was a promising but ultimately empty gesture, as no significant resources or major initiatives followed. While a few important steps have been taken – including the crackdown on illegal shipments of the deadly synthetic opioid fentanyl, and relaxing restrictions on reimbursements to large substance abuse treatment facilities - the administration has largely ignored the excellent recommendations of the White House special opioid commission.

Moreover, the post of permanent “drug czar” at the Office of National Drug Control Policy (ONDCP) remains vacant and the administration has threatened to drastically reduce the agency’s budget. Grants from the $1 billion 21st Century Cures Act failed to prioritize states hit hardest by the epidemic. Law enforcement and border controls are important, of course, but they are not the solution to this crisis: 40 percent of drug overdose deaths in 2016 involved a prescription opioid, according to the CDC.

The opioid crisis status as national public health emergency was recently renewed for another 90 days, providing a window of opportunity to end policy paralysis. The Rosenthal Center believes the administration should now set out an aggressive national agenda with the following achievable goals:

Appoint a qualified “drug czar” and support the existing senior staff at ONDCP and increase its budget to ensure this important office can properly coordinate drug policy across the many federal agencies engaged in drug control activities. Maintain ONDCP control over appropriate funds in other federal agencies.

Immediately allocate a 50 percent to 100 percent increases in the federal Substance Abuse Prevention and Treatment Block Grants to the states, to support their anti-drug programs.

Implement such recommendations of the White House opioid commission as wider use of drug courts, stricter prescription drug monitoring, improving doctor and professional training, and making overdose reversal drugs more available.

Work with Congress to approve a $100 billion long-term spending bill over the next decade with a focus on education, prevention and appropriate treatment, including the expansion of Medication-Assisted Treatment (MAT) with behavioral therapy and long-term residential treatment as essential components.

President Trump concluded his brief remarks about the opioid epidemic by saying, “the struggle will be long and it will be difficult – but, as Americans always do, in the end, we will succeed, we will prevail.” This is true. There is hope. But only if we have the commitment, consensus and the willingness to take action – and pay for it.

2nd February 2018

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The Rosenthal Report - January 2018

Rosenthal Reports

2017: A Year of Challenges and Missed Opportunities

The opioid epidemic continued to plague the nation last year, despite renewed efforts by cities, states and the Trump administration—which declared a public health emergency in October—to address the crisis. Urban and rural, white and black, rich and poor, young and old: no community or demographic was immune to the scourge of addiction and the unrelenting rise in overdose deaths. As the New York Times concluded in an article at the end of the year, the country’s addiction crisis “ranks among the great epidemics of our age.”

Drug overdose data for 2016, released by the CDC last year, confirmed the unrelenting advance of the epidemic: more than 63,000 people died, mostly adults between 25 and 54 and more men than women. There was a surprising uptick in deaths among African-Americans in urban counties, which shifted perceptions of the epidemic as a predominantly white and rural phenomenon. Deaths caused by the highly potent synthetic opioid fentanyl surged, as did overdoses from cocaine mixed with opioids. West Virginia, New Hampshire and Pennsylvania remained among the hardest hit states, as did the District of Columbia. But New York City also reported a record 1,374 drug overdose deaths, a nearly 47 percent spike over the previous year.

There were a few glimmers of hope. Many states implemented ambitious and well thought out anti-drug programs: the strategy in Massachusetts includes tougher prescription drug monitoring, wider use of overdose reversal drugs, and increasing the number of addiction treatment beds, which together is expected to drive down the number of deaths by 10 percent. The Trump health emergency announcement was a positive step that drew media attention to the epidemic. The White House special commission on opioids, to which I contributed expert testimony, produced an extensive report with recommendations that included an increase in medication-assisted treatment (MAT) which combines behavioral therapies with drugs to reduce withdrawal symptoms and drug cravings.

Unfortunately, the administration missed an opportunity to back the report and the emergency declaration with additional funding for drug treatment programs and services. At a time when drug overdoses are the leading cause of death among Americans under the age of 50, the GOP-controlled Congress tried but failed to repeal Obamacare and Medicaid expansion, which would have undermined programs that provide a critical share of addiction treatment dollars. Attorney General Sessions, for his part, signaled approval of maximum sentencing and incarceration for even minor drug offenses – tactics that we know do not address the underlying causes of addiction.

As the year unfolded, the Rosenthal Report tracked many of the issues that had an impact on the opioid epidemic. These included mandatory treatment for addiction; a barrage of lawsuits against opioid makers; the economic consequences of the crisis; treatment innovations; and new studies purporting to show that marijuana could be used as a safe alternative painkiller to opioids.

Most importantly, the Rosenthal Center continued to advocate for immediate emergency funding to the states. We proposed a 50 percent to 100 percent increase in the federal Substance Abuse Prevention and Treatment Block Grant, as well as a massive increase in funding, totaling $100 billion over the next decade, for a bold national plan to tackle this crisis. This money would be used to expand access to long-term residential treatment, which offers the best hope of recovery to vulnerable drug users most at risk of overdose; ensure that behavioral therapy is an essential component of MAT; and provide states with the ability to implement more education and prevention programs and the tools to get more addicts into comprehensive treatment.

Provisional data suggests that drug-related deaths continued to climb in 2017. And yet I still believe we can overcome this crisis. We have the knowledge, resources and expertise to treat the more than 20 million Americans with addiction problems, only a fraction of whom now receive help. We need the money and the political will to get the job done. This is the message of optimism I voiced last year - in the Rosenthal Report, in talks and media appearances, at professional conferences and in videos on our website – and will continue to do so in 2018.

2nd January 2018

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The Rosenthal Report - December 2017

Rosenthal Reports

In the Rosenthal Report for December, we look at:

The promise and risk of innovation to fight the opioid epidemic

How the drug industry is promoting “better” opioids with government help

Why we need to stay focused on addiction treatments that work

Innovation is the latest buzzword when addressing the opioid epidemic, backed by the Trump administration and the pharmaceutical industry as a silver bullet solution to the crisis. But as government and private companies increase investments in research and development, we risk losing sight of the many effective treatments and approaches already at our disposal, such as the residential care that is so hard to find by many who now need it. While innovation is critical to advance addiction treatment, we won’t find easy answers solely with technology and new medications.

Many new products are already coming to market. The FDA recently approved two: an electronic earpiece that blocks opioid withdrawal symptoms by sending an electronic pulse through four cranial nerves to reduce nausea, anxiety, and pain; and a “digital” pill equipped with sensors that lets doctors closely monitor a patient’s pain level and frequency of drug use through a small data-storage device attached to the abdomen.

Pharmaceutical companies are gearing up as well, developing new forms of supposedly “better” opioids – in many cases, with government help. In an unusual move, the administration is promising substantial funding for public-private partnerships with the drug industry to develop non-addictive painkillers as well as so-called abuse-deterrent opioids, which Big Pharma claims will help curb substance abuse.

This is a troubling approach. We need to change lives, not drugs. And we can’t depend on technology – for all its promise – to do the hard work of addiction recovery. More importantly, we need to make sure the treatments that do work are easily available to a growing addict population.

Overdose reversal drugs, for example, are highly effective. But many municipalities across the country can’t get them because of limited supply and rising prices (one brand, Evzio, now costs $4,500 for two doses, up from $690 in 2014). Evidence-based prevention programs can work, especially for children and teenagers, but they were given scant notice in the opioid commission report.

Promoting abuse-deterrent opioids, especially with taxpayer money, is “insanity,” as a New York Times editorial put it. Abuse-deterrent is a misleading term referring to pills that are harder to crush or alter for injection or snorting, but have the same addictive properties and therefore won’t prevent someone from ingesting opioids or becoming addicted.

The Rosenthal Center believes that residential therapy of varying lengths – therapy that treats the whole person, with proven clinical practices and peer-based counseling - offers the best chance of sustained recovery. Yet today there are many places in the country where residential facilities are not available or affordable for many people. Far too often we hear tragic stories of addicts’ lives lost during a desperate scramble to find treatment and the means to pay for it.

This is a failure of government policy and funding priorities. The Rosenthal Center will continue to strongly support increased funding to expand the treatments and programs that we know help save lives every day.

4th December 2017

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The Rosenthal Report - November 2017

Rosenthal Reports

The Government Mobilizes to Fight the Opioid Epidemic

Trump declares a “public health emergency”

White House commission outlines 56 recommendations

No new funding request undercuts implementation

Federal efforts to address the opioid epidemic gained momentum in October. President Trump declared a public health emergency and a week later his special opioid commission issued its final report with 56 wide-ranging recommendations. Unfortunately, neither the administration nor the commission requested any additional funding to back up the proposals, raising questions about how and when they would be implemented. The commission did press Congress to “appropriate sufficient funds” but did not identify how much is needed.

This was a missed opportunity. We know that effective treatment, especially long-term residential treatment, can save lives – but it also requires money. The current $1 billion for anti-drug initiatives available under the 21st Century Cures Act is insufficient, given the widening scope of the crisis. In an interview on Fox television news, I repeated a Rosenthal Center proposal to immediately double the existing federal block grants to the states, which would free up $1.9 billion for critical state programs. But experts estimate that at least ten billion a year is needed to cope with what the administration recognized as “the worst drug crisis in American history.”

The commission’s recommendations included many effective strategies already in place. Some focus on harm reduction, others on prevention and education, as well as prescription monitoring, doctor training and making overdose reversal drugs more available. It called for expanding drug courts and streamlining the way federal dollars are funneled to the states for anti-drug initiatives. To increase treatment capacity, the commission recommended lifting in all 50 states the regulation that limits the number of beds in treatment facilities that receive Medicaid support. The Center endorses this measure that would immediately open treatment to thousands of low-income Americans.

Otherwise, the report acknowledged the need for medication-assisted treatment (MAT) – which combines behavioral counseling with drugs to reduce withdrawal cravings – saying it was “underutilized” and should be expanded. But the report did not say how.

Given the scope of this crisis, we cannot make recommendations without committing more dollars. In its just released 2017 drug threat assessment report, the DEA found that overdose deaths, already at a high level, continue to rise due to the mixing of heroin with the highly potent synthetic opioid fentanyl, a drug more widely available than ever before. “It has never been a more important time to use all the tools at our disposal to fight this epidemic,” the report concluded. The Rosenthal Center will continue to send that message loud and clear to politicians, policymakers and the media.

3rd November 2017

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The Rosenthal Report - November 2017

Rosenthal Reports

The Government Mobilizes to Fight the Opioid Epidemic

Trump declares a “public health emergency”

White House commission outlines 56 recommendations

No new funding request undercuts implementation

Federal efforts to address the opioid epidemic gained momentum in October. President Trump declared a public health emergency and a week later his special opioid commission issued its final report with 56 wide-ranging recommendations. Unfortunately, neither the administration nor the commission requested any additional funding to back up the proposals, raising questions about how and when they would be implemented. The commission did press Congress to “appropriate sufficient funds” but did not identify how much is needed.

This was a missed opportunity. We know that effective treatment, especially long-term residential treatment, can save lives – but it also requires money. The current $1 billion for anti-drug initiatives available under the 21st Century Cures Act is insufficient, given the widening scope of the crisis. In an interview on Fox television news, I repeated a Rosenthal Center proposal to immediately double the existing federal block grants to the states, which would free up $1.9 billion for critical state programs. But experts estimate that at least ten billion a year is needed to cope with what the administration recognized as “the worst drug crisis in American history.”

The commission’s recommendations included many effective strategies already in place. Some focus on harm reduction, others on prevention and education, as well as prescription monitoring, doctor training and making overdose reversal drugs more available. It called for expanding drug courts and streamlining the way federal dollars are funneled to the states for anti-drug initiatives. To increase treatment capacity, the commission recommended lifting in all 50 states the regulation that limits the number of beds in treatment facilities that receive Medicaid support. The Center endorses this measure that would immediately open treatment to thousands of low-income Americans.

Otherwise, the report acknowledged the need for medication-assisted treatment (MAT) – which combines behavioral counseling with drugs to reduce withdrawal cravings – saying it was “underutilized” and should be expanded. But the report did not say how.

Given the scope of this crisis, we cannot make recommendations without committing more dollars. In its just released 2017 drug threat assessment report, the DEA found that overdose deaths, already at a high level, continue to rise due to the mixing of heroin with the highly potent synthetic opioid fentanyl, a drug more widely available than ever before. “It has never been a more important time to use all the tools at our disposal to fight this epidemic,” the report concluded. The Rosenthal Center will continue to send that message loud and clear to politicians, policymakers and the media.

3rd November 2017

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The Rosenthal Report - October 2017

Rosenthal Reports

In the Rosenthal Report for October, we look at:

How the federal government can help states fight the opioid epidemic, following the failure to repeal ACA and cut Medicaid

Mapping technology to pinpoint drug treatment gaps on Staten Island

The impact of involuntary commitment in New Hampshire and neighboring Massachusetts

The barrage of lawsuits against opioid makers

Provide emergency federal funding to the states for drug addiction programs

The failure by Congress to repeal the Affordable Care Act ensures, for now, that millions of Americans will continue to receive drug addiction treatment (Medicaid pays for about one-fifth of all substance abuse services). But there’s much more to be done to help the states implement robust anti-opioid prevention and drug treatment programs. Among the states with programs underway is New Jersey, which announced a comprehensive $200 million plan that supports Medicaid-based recovery programs and peer coaching for recovering addicts. Yet many financially strapped statehouses need more money. The federal government could kick in $940 million by providing an emergency 50 percent increase in block grants (New York State, for instance, would get $54 million). This would prime the funding pipeline for state programs, while we develop longer-term nationwide strategies and funding resources.

Mapping technology helps pinpoint gaps in addiction treatment

Why does the borough of Staten Island have the highest rate of drug overdose deaths in New York City? One factor, according to a new report by Columbia University and the Staten Island district attorney’s office, is that there are few treatment facilities available where the most drug overdoses occur. To reach this conclusion, researchers used mapping technology to match overdoses by ZIP code and treatment centers, a model that could be replicated in other locations to identify where treatment is most needed. The report, initiated by Bridget G. Brennan, the city’s special narcotics prosecutor, recommended expanding treatment options over law enforcement approaches, but mentioned only medically assisted treatment and the use of opioid withdrawal drugs like buprenorphine. This is only a first step to recovery, which must include behavioral therapy, and for those need it, long-term residential treatment for the best chance of success.

A tale of two states: how involuntary commitment policies can save lives

New Hampshire does not allow involuntary commitment, which places drug addicts into treatment. But across the state line, Massachusetts does. A recent report by NPR New Hampshire highlighted the stark outcomes of this policy. It described the death of a young man in New Hampshire from a fentanyl overdose as his parents sought treatment for him; meanwhile, in nearby Massachusetts a young woman was able to enter treatment under pressure from her parents and a drug court, and is now in recovery. These stories support the conviction of the Rosenthal Center that mandatory treatment is at least as successful as voluntary.

Those with drug-use problems don’t usually volunteer for treatment, and require suasion from family members or an employer and the enforcement of the court system. Last year, New Hampshire’s legislature shelved a proposal to change the law on involuntary treatment, undermining efforts to bring that state’s high opioid overdose death rate under control.

Opioid makers face barrage of legal actions

Lawsuits against the drug industry for its role in the opioid epidemic are piling up - and there may be more to come. Dozens of suits have already been brought by cities, counties and states to recoup costs incurred from the surge of drug overdose deaths linked to opioids. In the latest move, the attorney generals of 41 U.S. states said they are investigating pharmaceutical firms to see whether deception was involved in marketing opioids to doctors and patients. The legal strategy is similar to the one used in successful litigation against tobacco companies, which brought a $246 billion settlement in 1998 from cigarette manufacturers. The Rosenthal Center supports legal efforts that may secure money for drug addiction services, but recognizes that lawsuits alone are not the solution to this complex public health problem.

SAM (Smart Approaches to Marijuana): New report on the link between marijuana and opioid

Some preliminary studies have suggested that the use of medical marijuana in states where it is legal may reduce opioid use. But a new report published in the American Journal of Psychiatry found that cannabis use increased the risk of developing nonmedical prescription opioid use as well as opioid use disorder. Based on a survey of 30,000 Americans, the study demonstrated that marijuana users were more than twice as likely as non-users to move on to abuse prescription opioids, even when controlling for factors such as age, sex, race and ethnicity.

3rd October 2017

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The Rosenthal Report - October 2017

Rosenthal Reports

In the Rosenthal Report for October, we look at:

How the federal government can help states fight the opioid epidemic, following the failure to repeal ACA and cut Medicaid

Mapping technology to pinpoint drug treatment gaps on Staten Island

The impact of involuntary commitment in New Hampshire and neighboring Massachusetts

The barrage of lawsuits against opioid makers

Provide emergency federal funding to the states for drug addiction programs

The failure by Congress to repeal the Affordable Care Act ensures, for now, that millions of Americans will continue to receive drug addiction treatment (Medicaid pays for about one-fifth of all substance abuse services). But there’s much more to be done to help the states implement robust anti-opioid prevention and drug treatment programs. Among the states with programs underway is New Jersey, which announced a comprehensive $200 million plan that supports Medicaid-based recovery programs and peer coaching for recovering addicts. Yet many financially strapped statehouses need more money. The federal government could kick in $940 million by providing an emergency 50 percent increase in block grants (New York State, for instance, would get $54 million). This would prime the funding pipeline for state programs, while we develop longer-term nationwide strategies and funding resources.

Mapping technology helps pinpoint gaps in addiction treatment

Why does the borough of Staten Island have the highest rate of drug overdose deaths in New York City? One factor, according to a new report by Columbia University and the Staten Island district attorney’s office, is that there are few treatment facilities available where the most drug overdoses occur. To reach this conclusion, researchers used mapping technology to match overdoses by ZIP code and treatment centers, a model that could be replicated in other locations to identify where treatment is most needed. The report, initiated by Bridget G. Brennan, the city’s special narcotics prosecutor, recommended expanding treatment options over law enforcement approaches, but mentioned only medically assisted treatment and the use of opioid withdrawal drugs like buprenorphine. This is only a first step to recovery, which must include behavioral therapy, and for those need it, long-term residential treatment for the best chance of success.

A tale of two states: how involuntary commitment policies can save lives

New Hampshire does not allow involuntary commitment, which places drug addicts into treatment. But across the state line, Massachusetts does. A recent report by NPR New Hampshire highlighted the stark outcomes of this policy. It described the death of a young man in New Hampshire from a fentanyl overdose as his parents sought treatment for him; meanwhile, in nearby Massachusetts a young woman was able to enter treatment under pressure from her parents and a drug court, and is now in recovery. These stories support the conviction of the Rosenthal Center that mandatory treatment is at least as successful as voluntary.

Those with drug-use problems don’t usually volunteer for treatment, and require suasion from family members or an employer and the enforcement of the court system. Last year, New Hampshire’s legislature shelved a proposal to change the law on involuntary treatment, undermining efforts to bring that state’s high opioid overdose death rate under control.

Opioid makers face barrage of legal actions

Lawsuits against the drug industry for its role in the opioid epidemic are piling up - and there may be more to come. Dozens of suits have already been brought by cities, counties and states to recoup costs incurred from the surge of drug overdose deaths linked to opioids. In the latest move, the attorney generals of 41 U.S. states said they are investigating pharmaceutical firms to see whether deception was involved in marketing opioids to doctors and patients. The legal strategy is similar to the one used in successful litigation against tobacco companies, which brought a $246 billion settlement in 1998 from cigarette manufacturers. The Rosenthal Center supports legal efforts that may secure money for drug addiction services, but recognizes that lawsuits alone are not the solution to this complex public health problem.

SAM (Smart Approaches to Marijuana): New report on the link between marijuana and opioid

Some preliminary studies have suggested that the use of medical marijuana in states where it is legal may reduce opioid use. But a new report published in the American Journal of Psychiatry found that cannabis use increased the risk of developing nonmedical prescription opioid use as well as opioid use disorder. Based on a survey of 30,000 Americans, the study demonstrated that marijuana users were more than twice as likely as non-users to move on to abuse prescription opioids, even when controlling for factors such as age, sex, race and ethnicity.

TO SENATORS: REJECT OBAMACARE REPEAL, SAVE DRUG TREATMENT PROGRAMS

We’re facing a massive opioid epidemic that will kill more than 60,000 Americans this year: now is the worst time to pull the rug from critical drug treatment funding.

20th September 2017

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The Rosenthal Report - September 2017

Rosenthal Reports

We need a national strategy to address teenage opioid use

After declining for seven years, teenage drug overdose deaths grew by nearly 20 percent in 2015 in a worrying sign that the opioid crisis is reaching a younger and more vulnerable segment of the American population. New data from the Centers for Disease Control (CDC) found that 772 teens aged 15-19 died in 2015 from drug overdoses, compared to 658 the year before. This reverses a 26 percent fall in the rate of overdose deaths between 2007 and 2014.

The uptick in teen overdose deaths in 2015 is troubling for many reasons. Digging into the data, we see that teen overdose deaths were linked to the growing use of both heroin and synthetic opioids such as fentanyl. There was also a sharp 34 percent spike in deaths among teenage girls in the two years between 2013 and 2015, and a 15 percent increase for boys from 2014 to 2015. For both males and females, the majority of deaths were unintentional.

For some perspective, consider that teens still represent a small percentage of the 64,000 Americans – up 22 percent over 2015 - who died from drug overdoses in 2016. Yet the increase in teenage overdoses suggests that young people now have easier access to deadly drugs as well as a growing interest in them, after many years in which they had largely stayed away from drugs, alcohol and tobacco. Overall, the number of overdose deaths involving fentanyl or fentanyl analogues doubled from 2015 to 2016, the CDC found.

These findings come at a time when there are insufficient treatment resources dedicated to teenagers and adolescents. Even as drug use and overdoses rise, teen admissions to treatment facilities are going down. This reflects a continuing trend in the drug abuse treatment field that has long underserved adolescents. Although the overall number of clients in treatment fell by 19 percent between 2005 and 2015, the number for teens plummeted by 56 percent over the same time period, according to SAMHSA data.

The sudden rise in teenage overdose deaths in 2015 may be an aberration. But as the opioid crisis continues unabated, it is clear that young people are increasingly susceptible to addiction. Therefore, we must develop a national strategy to close the glaring gap in services for this age group. This should include prevention programs and treatment facilities targeted to young people and their unique developmental considerations. Intervening early when teens first show signs of addiction is the best way to avert a lifetime of drug use.

What we need to do:

Encourage federal, state and local authorities to increase funding to expand youth-oriented addiction programs, starting with prevention and outreach to stop or delay initiation of teen opioid use; provide more residential treatment programs of adequate duration and prioritize the involvement of families at all levels of treatment; and remove barriers to admission and broaden insurance coverage.

5th September 2017

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The Rosenthal Report - September 2017

Rosenthal Reports

We need a national strategy to address teenage opioid use

After declining for seven years, teenage drug overdose deaths grew by nearly 20 percent in 2015 in a worrying sign that the opioid crisis is reaching a younger and more vulnerable segment of the American population. New data from the Centers for Disease Control (CDC) found that 772 teens aged 15-19 died in 2015 from drug overdoses, compared to 658 the year before. This reverses a 26 percent fall in the rate of overdose deaths between 2007 and 2014.

The uptick in teen overdose deaths in 2015 is troubling for many reasons. Digging into the data, we see that teen overdose deaths were linked to the growing use of both heroin and synthetic opioids such as fentanyl. There was also a sharp 34 percent spike in deaths among teenage girls in the two years between 2013 and 2015, and a 15 percent increase for boys from 2014 to 2015. For both males and females, the majority of deaths were unintentional.

For some perspective, consider that teens still represent a small percentage of the 64,000 Americans – up 22 percent over 2015 - who died from drug overdoses in 2016. Yet the increase in teenage overdoses suggests that young people now have easier access to deadly drugs as well as a growing interest in them, after many years in which they had largely stayed away from drugs, alcohol and tobacco. Overall, the number of overdose deaths involving fentanyl or fentanyl analogues doubled from 2015 to 2016, the CDC found.

These findings come at a time when there are insufficient treatment resources dedicated to teenagers and adolescents. Even as drug use and overdoses rise, teen admissions to treatment facilities are going down. This reflects a continuing trend in the drug abuse treatment field that has long underserved adolescents. Although the overall number of clients in treatment fell by 19 percent between 2005 and 2015, the number for teens plummeted by 56 percent over the same time period, according to SAMHSA data.

The sudden rise in teenage overdose deaths in 2015 may be an aberration. But as the opioid crisis continues unabated, it is clear that young people are increasingly susceptible to addiction. Therefore, we must develop a national strategy to close the glaring gap in services for this age group. This should include prevention programs and treatment facilities targeted to young people and their unique developmental considerations. Intervening early when teens first show signs of addiction is the best way to avert a lifetime of drug use.

What we need to do:

Encourage federal, state and local authorities to increase funding to expand youth-oriented addiction programs, starting with prevention and outreach to stop or delay initiation of teen opioid use; provide more residential treatment programs of adequate duration and prioritize the involvement of families at all levels of treatment; and remove barriers to admission and broaden insurance coverage.

5th September 2017

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The Rosenthal Report - August 2017

Rosenthal Reports

White House drug commission calls for Trump to declare a national drug emergency

Commission’s strategy lacks clear funding goals

What’s needed is a bold $100 billion plan to fight the opioid epidemic

The White House opioid commission’s call in July for President Trump to declare a “national health emergency” to fight the opioid epidemic is an important step forward. So too are the forward-thinking policy guidelines issued by the commission, which I addressed in June. Using stark language, the commission’s interim report urged the President and Congress to focus on funding and launching initiatives to combat a drug “scourge” that will eventually affect every American, the report warned.

Many of the commission’s proposals go to the heart of the crisis, and target policy areas important to the Rosenthal Center. These range from increasing treatment capacity – especially residential treatment – through Medicaid; expanding Medication-Assisted Treatment (MAT); providing overdose reversal drugs to all law enforcement; and disrupting the flow of the deadly synthetic opioid fentanyl, which the commission calls “the next grave challenge on the opioid front.”

While moving in the right direction, the report does not go far enough. It failed to commit a specific amount of money to the national emergency at a time when 142 Americans die every day from drug overdoses. And it does not address a number of specific policy ideas that are key to successfully confronting this epidemic.

As we go to press, it’s uncertain whether President Trump will declare a health emergency and if he will support a large funding commitment. After all, as the legislative showdown over healthcare reform recently demonstrated, President Trump and the GOP-led Congress were willing to gut Medicaid and scale back essential benefits that would have devastated drug treatment programs.

With this in mind, the Rosenthal Center calls for bipartisan leadership and a comprehensive $100 billion national action program that expands on the commission’s findings and sets more specific goals and explicit policy language as follows:

Immediately allocate $100 billion to the states. This will incentivize the states to match funding to expand existing programs and design and build up new initiatives that directly address the needs of their communities.

Ensure that behavioral therapy is an essential component of medication- assisted treatment (MAT). While the commission calls for expanding MAT, it does not specifically mention the importance of behavioral therapy and counseling. Under federal SAMHSA guidelines, MAT must include both medication and therapy as a way to help addicts reorder their lives and provide them with self-awareness and a new social network for sustained recovery.

Expand access to long-term residential treatment. With resources strained by the fast moving epidemic, few states today have sufficient capacity to provide long-term treatment for the skyrocketing addict population. The commission is right to prioritize this goal, as long-term treatment can help break the cycle of serial short-term admissions that often result in subsequent relapse and in many cases, death.

Renewed focus on specific addict populations, including vulnerable adolescents. The commission did not specifically mention adolescents, even though the Surgeon General estimates that one million adolescents (12 to 17) are in need of drug treatment but routinely fail to receive it. Teen admissions to drug programs plummeted by almost 50 percent between 2004 and 2014 to just over 78,000, due in part to the closing of dedicated facilities. We must ensure that adolescents who are prey to opioid addiction receive treatment at an early stage of their drug misuse to prevent a new generation of young adult opioid addicts tomorrow.

Extend the Continuum of Care service model. The commission correctly proposed ensuring a continuum of care into the criminal justice system, noting that treatment during and after incarceration works to reduce recidivism and lowers mortality risk. We should also enlarge the model to include offsite services to homeless shelters, schools and addicts’ homes.

3rd August 2017

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The Rosenthal Report - August 2017

Rosenthal Reports

White House drug commission calls for Trump to declare a national drug emergency

Commission’s strategy lacks clear funding goals

What’s needed is a bold $100 billion plan to fight the opioid epidemic

The White House opioid commission’s call in July for President Trump to declare a “national health emergency” to fight the opioid epidemic is an important step forward. So too are the forward-thinking policy guidelines issued by the commission, which I addressed in June. Using stark language, the commission’s interim report urged the President and Congress to focus on funding and launching initiatives to combat a drug “scourge” that will eventually affect every American, the report warned.

Many of the commission’s proposals go to the heart of the crisis, and target policy areas important to the Rosenthal Center. These range from increasing treatment capacity – especially residential treatment – through Medicaid; expanding Medication-Assisted Treatment (MAT); providing overdose reversal drugs to all law enforcement; and disrupting the flow of the deadly synthetic opioid fentanyl, which the commission calls “the next grave challenge on the opioid front.”

While moving in the right direction, the report does not go far enough. It failed to commit a specific amount of money to the national emergency at a time when 142 Americans die every day from drug overdoses. And it does not address a number of specific policy ideas that are key to successfully confronting this epidemic.

As we go to press, it’s uncertain whether President Trump will declare a health emergency and if he will support a large funding commitment. After all, as the legislative showdown over healthcare reform recently demonstrated, President Trump and the GOP-led Congress were willing to gut Medicaid and scale back essential benefits that would have devastated drug treatment programs.

With this in mind, the Rosenthal Center calls for bipartisan leadership and a comprehensive $100 billion national action program that expands on the commission’s findings and sets more specific goals and explicit policy language as follows:

Immediately allocate $100 billion to the states. This will incentivize the states to match funding to expand existing programs and design and build up new initiatives that directly address the needs of their communities.

Ensure that behavioral therapy is an essential component of medication- assisted treatment (MAT). While the commission calls for expanding MAT, it does not specifically mention the importance of behavioral therapy and counseling. Under federal SAMHSA guidelines, MAT must include both medication and therapy as a way to help addicts reorder their lives and provide them with self-awareness and a new social network for sustained recovery.

Expand access to long-term residential treatment. With resources strained by the fast moving epidemic, few states today have sufficient capacity to provide long-term treatment for the skyrocketing addict population. The commission is right to prioritize this goal, as long-term treatment can help break the cycle of serial short-term admissions that often result in subsequent relapse and in many cases, death.

Renewed focus on specific addict populations, including vulnerable adolescents. The commission did not specifically mention adolescents, even though the Surgeon General estimates that one million adolescents (12 to 17) are in need of drug treatment but routinely fail to receive it. Teen admissions to drug programs plummeted by almost 50 percent between 2004 and 2014 to just over 78,000, due in part to the closing of dedicated facilities. We must ensure that adolescents who are prey to opioid addiction receive treatment at an early stage of their drug misuse to prevent a new generation of young adult opioid addicts tomorrow.

Extend the Continuum of Care service model. The commission correctly proposed ensuring a continuum of care into the criminal justice system, noting that treatment during and after incarceration works to reduce recidivism and lowers mortality risk. We should also enlarge the model to include offsite services to homeless shelters, schools and addicts’ homes.

3rd August 2017

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The Rosenthal Report - July 2017

Rosenthal Reports

“We are facing an addiction crisis likely to be the most deadly drug epidemic in the nation’s history.”

In June, I testified in Washington, D.C. at the first meeting of the new Presidential Commission on Combating Drug Addiction and the Opioid Crisis, speaking on behalf of the Rosenthal Center and as deputy chairman of the National Council on Alcoholism and Drug Addiction.

I used the occasion to bluntly tell members we are facing an addiction crisis likely to be the most deadly drug epidemic in the nation’s history. The numbers tell a tragic story: in 2016 nearly 60,000 Americans died from drug overdoses, mostly from opiates, a 20 percent increase over the year before. Over the next decade, opioids could kill between 500,000 and 650,000 Americans - nearly as many as HIV/AIDS killed in the 1980s, and equal to the number of those who will die from prostate and breast cancer - if the crisis of addiction and overdose accelerates, a STAT News report concluded.

The crisis is tearing at the fabric of our society, devastating families and communities as it spreads back to inner city neighborhoods, as well as to suburbs, from the rural areas hit hardest by the current epidemic. Addiction now touches almost every race, ethnicity and area of the country. According to recent data, drug overdoses are the leading cause of death for Americans under the age of 50; for the first time in a century the overall death rate for Americans in the prime of life is rising.

The terrifying reality is that nothing we’re doing today has been able to stop the spread of opioid addiction, an observation I made that was quoted in US News & World Report’s coverage of the hearing. Despite prescription monitoring programs, new pain management guidelines, and a raft of prevention and education programs, deaths from heroin and super-potent synthetics like fentanyl have gone through the roof, overwhelming hospital emergency rooms and healthcare workers.

We are engulfed in a perfect storm of disabling forces. Drugs like fentanyl and its even more powerful analogue carafentanil (an elephant tranquilizer) can be easily purchased online over the “dark web,” which is difficult for law enforcement to detect and disrupt. Enough powdery fentanyl to get 50,000 users high – or, more likely, to kill them – can fit into a first-class size envelope and be shipped anywhere.

Yet we do have the ability and knowhow to manage addiction. With the right treatment most addicts can come back to a full and fulfilling life for their families and for society.

Securing the future of Medicaid is critical to this goal. Cutting funding would severely endanger the lives of addicts, especially those with few social or economic resources. Medicaid is the largest payer for addiction services across the country, and to gut this entitlement program now would be “immoral and mean-spirited,” I said in a statement quoted by the New York Daily News.

If it does nothing else, the Commission should recommend the expansion of long-term residential treatment programs. Far too frequently, patients become trapped in a cycle of serial admissions and short-term treatment programs that are ineffective and inadequate, and often amount to merely postponing a fatal overdose, a comment that was mentioned in a PBS Newshour report on the hearing. For these patients, long-term residential treatment is most successful -although few states have sufficient long-term treatment capacity, and only one in ten addicts get the treatment they need.

I would hope the Commission, chaired by New Jersey governor Chris Christie, along with the Trump administration, Congress and state and local officials, listen carefully to what I and other experts had to say – and more importantly, that they take action sooner rather than later to seriously address this national health emergency.

6th July 2017

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The Rosenthal Report - July 2017

Rosenthal Reports

“We are facing an addiction crisis likely to be the most deadly drug epidemic in the nation’s history.”

In June, I testified in Washington, D.C. at the first meeting of the new Presidential Commission on Combating Drug Addiction and the Opioid Crisis, speaking on behalf of the Rosenthal Center and as deputy chairman of the National Council on Alcoholism and Drug Addiction.

I used the occasion to bluntly tell members we are facing an addiction crisis likely to be the most deadly drug epidemic in the nation’s history. The numbers tell a tragic story: in 2016 nearly 60,000 Americans died from drug overdoses, mostly from opiates, a 20 percent increase over the year before. Over the next decade, opioids could kill between 500,000 and 650,000 Americans - nearly as many as HIV/AIDS killed in the 1980s, and equal to the number of those who will die from prostate and breast cancer - if the crisis of addiction and overdose accelerates, a STAT News report concluded.

The crisis is tearing at the fabric of our society, devastating families and communities as it spreads back to inner city neighborhoods, as well as to suburbs, from the rural areas hit hardest by the current epidemic. Addiction now touches almost every race, ethnicity and area of the country. According to recent data, drug overdoses are the leading cause of death for Americans under the age of 50; for the first time in a century the overall death rate for Americans in the prime of life is rising.

The terrifying reality is that nothing we’re doing today has been able to stop the spread of opioid addiction, an observation I made that was quoted in US News & World Report’s coverage of the hearing. Despite prescription monitoring programs, new pain management guidelines, and a raft of prevention and education programs, deaths from heroin and super-potent synthetics like fentanyl have gone through the roof, overwhelming hospital emergency rooms and healthcare workers.

We are engulfed in a perfect storm of disabling forces. Drugs like fentanyl and its even more powerful analogue carafentanil (an elephant tranquilizer) can be easily purchased online over the “dark web,” which is difficult for law enforcement to detect and disrupt. Enough powdery fentanyl to get 50,000 users high – or, more likely, to kill them – can fit into a first-class size envelope and be shipped anywhere.

Yet we do have the ability and knowhow to manage addiction. With the right treatment most addicts can come back to a full and fulfilling life for their families and for society.

Securing the future of Medicaid is critical to this goal. Cutting funding would severely endanger the lives of addicts, especially those with few social or economic resources. Medicaid is the largest payer for addiction services across the country, and to gut this entitlement program now would be “immoral and mean-spirited,” I said in a statement quoted by the New York Daily News.

If it does nothing else, the Commission should recommend the expansion of long-term residential treatment programs. Far too frequently, patients become trapped in a cycle of serial admissions and short-term treatment programs that are ineffective and inadequate, and often amount to merely postponing a fatal overdose, a comment that was mentioned in a PBS Newshour report on the hearing. For these patients, long-term residential treatment is most successful -although few states have sufficient long-term treatment capacity, and only one in ten addicts get the treatment they need.

I would hope the Commission, chaired by New Jersey governor Chris Christie, along with the Trump administration, Congress and state and local officials, listen carefully to what I and other experts had to say – and more importantly, that they take action sooner rather than later to seriously address this national health emergency.

6th July 2017

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The Rosenthal Report - June 2017

Rosenthal Reports

In this month’s report, we explain why Attorney General Jeff Sessions’ tough sentencing directive for low-level drug crimes is the wrong way to fight drug abuse and underscores the Trump administration’s mixed messages on the opioid crisis. Our series on statewide initiatives examines Kentucky’s efforts to contain its opioid epidemic and one of the nation’s highest rates of overdose deaths.

Memo to Trump: Locking Up Drug Addicts Won’t End the Opioid Epidemic

U.S. Attorney General Jeff Sessions told federal prosecutors in May to impose harsh, mandatory minimum sentences for even low level and nonviolent drug crimes, scuttling Obama-era leniency toward offenders not associated with drug gangs or trafficking. Sessions’ policy reversal signals a return to the failed mass-incarceration strategies deployed during the “war on drugs” in the 1980s and 1990s, and is especially misguided as the nation grapples with a devastating opioid epidemic.

We are concerned about the potential consequences of a new dragnet of stricter enforcement and punishment for less serious drug offenses committed by substance abusers. This doesn’t mean we are soft on crime: by all means, put drug-dealing kingpins in prison. Instead of locking addicts in prison, we can leverage the interaction with the criminal justice system to provide them with opportunities for recovery.

Tough, mandatory minimum sentencing removes the possibility for creative sentencing by judges to place addicts in programs as an alternative to incarceration. Following the Obama guidelines, more than 30 states have already overhauled sentencing laws, introducing limited prison terms, expanding drug treatment programs and drug courts, which place most offenders in treatment.

Addicts require encouragement and most frequently coercion to enter treatment, and courts can help. Vanessa Vitolo, a recovering heroin addict who told her harrowing story to President Trump and his new opioid commission, is typical. As a young woman she got hooked on drugs, cycled in and out of jail and found herself homeless and feeling “lost in every aspect of the word,” she recalled. With help from her parents, and sentencing from a drug court, Vitolo finally received long-term treatment. Today, three years later, she is stable and in recovery, with a job and an apartment.

Vanessa’s story highlights the long road to recovery, and the role the criminal justice system can play. Let’s use guidelines for sentencing to get more addicts into treatment. It is also vital to create more treatment units within our prisons, and establish support systems outside prison so that recovering addicts are not just let on the street. This makes sense to maintain their health and safety as well as that of society.

President Trump’s opioid commission has a chance to be forward thinking and take advantage of decades of experience that the criminal justice system has had with treatment providers. Sessions’ sentencing directive is regressive. Instead of pounding the table for law and order, we need to continue the integration of the criminal justice system and substance abuse treatment programs into a comprehensive life-enhancing strategy.

The States Take Action: Kentucky

Like other Central Appalachian states, Kentucky has been hit hard by the opioid epidemic. There were 1,248 fatal overdoses in 2015, a 16 percent increase over the year before; the death rate was 29.9 per 100,000 population, the nation’s third highest. Contributing factors include poverty, complex injuries suffered by coal minors, and lax prescribing practices. Kentucky is one of 13 states in which the annual number of opioid painkiller prescriptions exceeds the number of residents. In Clay County, for example, with a population of 21,000, pharmacies dispensed more than 2.8 million doses of opioid pain killers in 2016, or 150 doses for every man, woman and child in the area, according to a Kaiser Health News report.

In early 2017,Governor Matt Bevin outlined Kentucky’s anti-opioid strategy at the National Prescription Drug Use and Heroin Summit. The plan includes a new law limiting opioid painkiller prescriptions to a 3-day supply; education programs on neonatal abstinence syndrome (a massive problem in the state); and ensuring over the counter access to the overdose reversal drug naloxone. To address an acute lack of treatment beds, Kentucky has applied for a waiver from the Medicaid rule that prohibits federal dollars being used for addiction treatment facilities with more than 16 beds. A 2016 survey by television station WCPO found that in eight counties in northern Kentucky some 30,000 people needed substance abuse treatment, but that there was only capacity for one-third of them in the region.

COMMENTARY

Obtaining a Medicaid waiver to the 16-bed limit provision will eventually increase the number of desperately needed long-term treatment beds, but this will take time. Meanwhile, threatened cuts to Medicaid funding and the possible repeal of the Affordable Care Act (ACA) by Congress would have an immediate and devastating impact on the state’s large low-income population (nearly 440,000 residents joined the Medicaid rolls under ACA). While Medicaid expansion did make some opioid drugs more available legally, it also made treatment more accessible, a story in the Atlantic magazine pointed out. In Clay County, where 60 percent of residents receive Medicaid benefits, opioid overdose deaths fell from 27 in 2011 to 4 in 2016 due in part to increased treatment options and the wider availability of drugs like suboxone, which reduces symptoms of opiate addiction and withdrawal. Changes to Medicaid funding and eligibility would imperil these important gains as Kentucky addresses its opioid crisis.

6th June 2017

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The Rosenthal Report - June 2017

Rosenthal Reports

In this month’s report, we explain why Attorney General Jeff Sessions’ tough sentencing directive for low-level drug crimes is the wrong way to fight drug abuse and underscores the Trump administration’s mixed messages on the opioid crisis. Our series on statewide initiatives examines Kentucky’s efforts to contain its opioid epidemic and one of the nation’s highest rates of overdose deaths.

Memo to Trump: Locking Up Drug Addicts Won’t End the Opioid Epidemic

U.S. Attorney General Jeff Sessions told federal prosecutors in May to impose harsh, mandatory minimum sentences for even low level and nonviolent drug crimes, scuttling Obama-era leniency toward offenders not associated with drug gangs or trafficking. Sessions’ policy reversal signals a return to the failed mass-incarceration strategies deployed during the “war on drugs” in the 1980s and 1990s, and is especially misguided as the nation grapples with a devastating opioid epidemic.

We are concerned about the potential consequences of a new dragnet of stricter enforcement and punishment for less serious drug offenses committed by substance abusers. This doesn’t mean we are soft on crime: by all means, put drug-dealing kingpins in prison. Instead of locking addicts in prison, we can leverage the interaction with the criminal justice system to provide them with opportunities for recovery.

Tough, mandatory minimum sentencing removes the possibility for creative sentencing by judges to place addicts in programs as an alternative to incarceration. Following the Obama guidelines, more than 30 states have already overhauled sentencing laws, introducing limited prison terms, expanding drug treatment programs and drug courts, which place most offenders in treatment.

Addicts require encouragement and most frequently coercion to enter treatment, and courts can help. Vanessa Vitolo, a recovering heroin addict who told her harrowing story to President Trump and his new opioid commission, is typical. As a young woman she got hooked on drugs, cycled in and out of jail and found herself homeless and feeling “lost in every aspect of the word,” she recalled. With help from her parents, and sentencing from a drug court, Vitolo finally received long-term treatment. Today, three years later, she is stable and in recovery, with a job and an apartment.

Vanessa’s story highlights the long road to recovery, and the role the criminal justice system can play. Let’s use guidelines for sentencing to get more addicts into treatment. It is also vital to create more treatment units within our prisons, and establish support systems outside prison so that recovering addicts are not just let on the street. This makes sense to maintain their health and safety as well as that of society.

President Trump’s opioid commission has a chance to be forward thinking and take advantage of decades of experience that the criminal justice system has had with treatment providers. Sessions’ sentencing directive is regressive. Instead of pounding the table for law and order, we need to continue the integration of the criminal justice system and substance abuse treatment programs into a comprehensive life-enhancing strategy.

The States Take Action: Kentucky

Like other Central Appalachian states, Kentucky has been hit hard by the opioid epidemic. There were 1,248 fatal overdoses in 2015, a 16 percent increase over the year before; the death rate was 29.9 per 100,000 population, the nation’s third highest. Contributing factors include poverty, complex injuries suffered by coal minors, and lax prescribing practices. Kentucky is one of 13 states in which the annual number of opioid painkiller prescriptions exceeds the number of residents. In Clay County, for example, with a population of 21,000, pharmacies dispensed more than 2.8 million doses of opioid pain killers in 2016, or 150 doses for every man, woman and child in the area, according to a Kaiser Health News report.

In early 2017,Governor Matt Bevin outlined Kentucky’s anti-opioid strategy at the National Prescription Drug Use and Heroin Summit. The plan includes a new law limiting opioid painkiller prescriptions to a 3-day supply; education programs on neonatal abstinence syndrome (a massive problem in the state); and ensuring over the counter access to the overdose reversal drug naloxone. To address an acute lack of treatment beds, Kentucky has applied for a waiver from the Medicaid rule that prohibits federal dollars being used for addiction treatment facilities with more than 16 beds. A 2016 survey by television station WCPO found that in eight counties in northern Kentucky some 30,000 people needed substance abuse treatment, but that there was only capacity for one-third of them in the region.

COMMENTARY

Obtaining a Medicaid waiver to the 16-bed limit provision will eventually increase the number of desperately needed long-term treatment beds, but this will take time. Meanwhile, threatened cuts to Medicaid funding and the possible repeal of the Affordable Care Act (ACA) by Congress would have an immediate and devastating impact on the state’s large low-income population (nearly 440,000 residents joined the Medicaid rolls under ACA). While Medicaid expansion did make some opioid drugs more available legally, it also made treatment more accessible, a story in the Atlantic magazine pointed out. In Clay County, where 60 percent of residents receive Medicaid benefits, opioid overdose deaths fell from 27 in 2011 to 4 in 2016 due in part to increased treatment options and the wider availability of drugs like suboxone, which reduces symptoms of opiate addiction and withdrawal. Changes to Medicaid funding and eligibility would imperil these important gains as Kentucky addresses its opioid crisis.

6th June 2017

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President Trump: don’t gut the budget of the White House Office of National Drug Control Policy!

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Slashing spending to just $24 million from $388 million will harm nation-wide efforts to fight the deadly opioid epidemic.

The Rosenthal Report - May 2017

Rosenthal Reports

MAINSTREAMING MARIJUANA

As the Trump administration signals support for hard line anti-drug policies, Canada is poised to legalize recreational marijuana nationwide – only the second country to do so. Meanwhile, support is growing for more research into using pot as a painkiller to help patients avoid opioid addiction. This month’s Report looks at these developments and the potential impact on perceptions and marijuana use. Our series on statewide initiatives to confront the opioid crisis focuses on Vermont and New Hampshire.

CANADA OPTS FOR POT LEGALIZATION

Canadian Prime Minister Justin Trudeau has introduced legislation that would legalize recreational use of marijuana nationwide by July 2018, a move approved by seven out of ten Canadians and designed to keep marijuana out of the hands of young people. Canada now has the world’s highest rates of youth cannabis use—21 percent of teens 15 to 19 and 30 percent of young adults 20 to 24.

Bill Blair, who will shepherd the legislation through the Canadian Parliament, makes the case that, “Criminal prohibition has failed to protect our kids and our communities.” Ralph Goodale, the nation’s public safety minister concurs, saying, “If your objective is to protect public health and safety and keep cannabis out of the hands of minors, and stop the flow of illegal profits to organized crime, then the law as it stands today has been an abject failure.”

During his campaign, Trudeau promised to expand legalization to recreational marijuana from court mandated medical marijuana. Details of the new measure follow recommendations of a federal taskforce, and include federal control over licensing and production and provincial regulation of how it can be sold.

Pricing and taxation will be jointly decided, and, after the nation’s experience with tobacco—when high prices, rather than reducing consumption, created a black market in cigarettes—should be low enough to limit illicit sales—as should harsh penalties proposed by the legalization measure.

Giving or selling pot to teens or “using youth to commit a cannabis-related offense” could land you in prison for 14 years. Lesser cannabis-related felonies, such as creating, packaging or labeling “products that are appealing to youth” will carry fines and prison terms. Growing, importing, exporting, or selling marijuana without a federal license will remain serious federal offenses.

The federal minimum age to buy marijuana will be 18, but the provinces can set higher minimum ages. Adults can possess as much as 30 grams of pot in public and families are allowed to grow four marijuana plants (to a maximum height of one meter). Aggressive marketing will be discouraged, product information limited largely to brand name, ingredients, strain of marijuana, and the government may insist on plain packaging. Police would be allowed to administer a saliva test to motorists to screen for THC, the psychoactive ingredient in marijuana.

In the workplace, employees would not have the right to freely use marijuana and are still expected to show up sober and ready to work, an assessment in the Globe and Mail newspaper concluded. In the province of Ontario, specifically, restrictions on smoking tobacco in the workplace would apply equally to the smoking of marijuana.

Given Trudeau’s Liberal Party majority, and support from the left-leaning New Democratic Party, recreational pot legalization is expected to pass easily. Conservative Party members voiced opposition, asserting that legalization would only increase adolescent marijuana use, while doctors – who have long had misgivings about medical marijuana – expressed grave concerns about the impact on youth.

The Canadian Pediatric Society warns that legalization does not mean the drug is safe. The doctors hold that one in seven teenagers who start using cannabis develop cannabis-use disorder and, though the adult brain seems able to recover from chronic pot use in just a few weeks, teens who smoke pot frequently can do long-lasting damage to their brains. Concerns about danger to the adolescent brain prompted the Canadian Medical Association to urge the government to ban the sale of marijuana to people under 21 and to restrict the amount and potency of the drug available to those under 25.

Protecting youth, Health Minister Jane Philpott maintains, is “at the center” of the legalization measure, and the government promises, “a robust public education campaign to inform youth of the risks and harms of cannabis use.” Clearly, one is needed, for Canadian Youth Perceptions on Cannabis, a study released at the end of January by the nonprofit Canadian Centre on Substance Abuse found “Young people think marijuana is neither addictive nor harmful.”

Speaking in support of the marijuana measure, Blair maintains that legalization is not aimed at promoting use of the drug or to maximize tax revenues. “In every other jurisdiction that has gone down the road of legalization, they focused primarily on a commercial regulatory framework. In Canada, it’s a public-health framework.”

Commentary

Canada’s plan for legalization contains much that is attractive to those who believe—as we do—that the paramount issue is limiting adolescent marijuana use. Legalization in the United States has, as opponents point out, led to increased teen use of the drug. Advocates for the Canadian plan contend that what they propose should not raise the nation’s already sky-high rate of youthful use. We doubt that any measure sanctioning adult use can prevent that.

TRADING PLACES: POT OR PAINKILLERS?

Researchers are becoming interested in how certain marijuana components could be used in controlled settings to help curb the opioid crisis. While U.S. Attorney General Jeff Sessions has mocked the idea as “stupid,” recent studies suggest that weed may be a safe substitute for opioid painkillers as well as an aid to curbing opioid abuse. “Epidemics require a paradigm shift in thinking about all possible solutions,” Yasmina Hurd, a neuroscientist at Mount Sinai Hospital in New York, argued in Trends in Neuroscience, explaining the growing interest in pot for these purposes. “We have to be open to marijuana because there are components of the plant that seem to have therapeutic properties.”

At this point, however, studies suggest only correlations between medical marijuana use and reducing chronic pain and opioid addiction. Preclinical animal models have demonstrated that CBD, a non-psychoactive element in marijuana, reduces the rewarding properties of opioid drugs and withdrawal symptoms. A small pilot study by Dr. Hurd mirrored these conclusions, as did research at the University of Michigan and a RAND Corporation paper with researchers at University of California, Irvine that compared states with and without medical marijuana dispensaries.

While intriguing, these initial findings are largely observational and anecdotal. They do not support changing current clinical practice towards cannabis, as the lead author of the Michigan study, Keith Boehnke, has stated. For one thing, these studies were conducted with patients at medical dispensaries who are more inclined to endorse the benefits of medicinal marijuana. Still, it is worthwhile exploring pot as an alternative to dangerous prescription opioid painkillers or to reduce opioid addiction. Research must be pursued in long-term, large-scale clinical studies that focus solely on the CBD component and not THC, a powerful psychoactive element in marijuana.

THE STATES TAKE ACTION: VERMONT AND NEW HAMPSHIRE

These neighboring New England states are struggling to contain the opioid epidemic that has ravaged their communities. Drug overdose mortality rates in 2015 reached 16.7 per 100,000 inhabitants in Vermont, and 34.3 n New Hampshire - one of the nation’s highest, according to the Centers for Disease Control and Prevention.

Vermont

In 2014 Vermont’s then-governor Peter Shumlin sounded the alarm about his state’s intensifying opioid epidemic, declaring a “full-blown crisis” with a spiraling number of drug overdoses and persons seeking treatment. The state legislature responded with measures to expand the use of overdose reversal drugs; introduce prescription rationing (as of January 2017); promote treatment options in lieu of prosecution and incarceration; and develop the state’s “spoke-and-hub” treatment infrastructure of centralized and local care.

After leveling off for a few years, the number of Vermonters who died from drug overdoses spiked in 2016 to 104, up from 66 the year before, almost evenly split between heroin and fentanyl overdoses. The victims represented a cross section of the state’s population: blue collar and professional class, rural and urban, old and young, and roughly 30 percent were women, the Vermont website Seven Days reported. Vermont’s anti-opioid efforts have had some impact. Indeed, the overdose numbers could have been worse if not for the widespread distribution of the overdose reversal drug Narcan, and the opening of more treatment facilities and a reduction in waiting times.

New Hampshire

Despite a relatively small population of 1.4 million, more than double neighboring Vermont, New Hampshire is often called “ground zero” of the rural opioid epidemic. In 2015, the state reported 439 drug overdose deaths - the second highest per capita rate in the nation after West Virginia – and 478 deaths are estimated for 2016.

The state response has focused on expanding access to treatment (New Hampshire ranked second to last nationwide in access to treatment), addressing a shortage of trained staff in recovery programs, and increasing the number of doctors licensed to prescribe Suboxone, a drug that eases withdrawal symptoms. Other measures include a drug crisis hotline; the Safe Station program, where addicts can seek help and referrals at fire stations; and stricter prescription monitoring rules that went into effect at the start of 2017. More than 10,000 persons have received addiction treatment after gaining coverage through the Medicaid expansion under the Affordable Care Act.

Holly Cekala, executive director of Hope for New Hampshire, a recovery community nonprofit, says the state is making strides to confront the epidemic and has come a long way from the “treatment apocalypse” it faced when the crisis first unfolded. But considering the high number of overdoses and waiting times for residential treatment – averaging four to six weeks – “there’s still a lot of work to be done,” she told the Rosenthal Report.

Commentary

Vermont and New Hampshire are taking the right steps to control the opioid epidemic, putting in place programs that will help save lives and get addicts into effective treatment. In both states, there is a range of options including outpatient and residential treatment lasting up to 90 days, including medication-assisted treatment (MAT) – especially in Vermont. Hard-hit New Hampshire needs to increase the number of residential treatment places and add more recovery housing; raise Medicaid reimbursement payments to allow more lower-income patients to enter treatment; and provide more prison-based drug treatment programs. It’s a resolutely stubborn public health crisis that will take time and determination to overcome.

4th May 2017

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The Rosenthal Report - May 2017

Rosenthal Reports

MAINSTREAMING MARIJUANA

As the Trump administration signals support for hard line anti-drug policies, Canada is poised to legalize recreational marijuana nationwide – only the second country to do so. Meanwhile, support is growing for more research into using pot as a painkiller to help patients avoid opioid addiction. This month’s Report looks at these developments and the potential impact on perceptions and marijuana use. Our series on statewide initiatives to confront the opioid crisis focuses on Vermont and New Hampshire.

CANADA OPTS FOR POT LEGALIZATION

Canadian Prime Minister Justin Trudeau has introduced legislation that would legalize recreational use of marijuana nationwide by July 2018, a move approved by seven out of ten Canadians and designed to keep marijuana out of the hands of young people. Canada now has the world’s highest rates of youth cannabis use—21 percent of teens 15 to 19 and 30 percent of young adults 20 to 24.

Bill Blair, who will shepherd the legislation through the Canadian Parliament, makes the case that, “Criminal prohibition has failed to protect our kids and our communities.” Ralph Goodale, the nation’s public safety minister concurs, saying, “If your objective is to protect public health and safety and keep cannabis out of the hands of minors, and stop the flow of illegal profits to organized crime, then the law as it stands today has been an abject failure.”

During his campaign, Trudeau promised to expand legalization to recreational marijuana from court mandated medical marijuana. Details of the new measure follow recommendations of a federal taskforce, and include federal control over licensing and production and provincial regulation of how it can be sold.

Pricing and taxation will be jointly decided, and, after the nation’s experience with tobacco—when high prices, rather than reducing consumption, created a black market in cigarettes—should be low enough to limit illicit sales—as should harsh penalties proposed by the legalization measure.

Giving or selling pot to teens or “using youth to commit a cannabis-related offense” could land you in prison for 14 years. Lesser cannabis-related felonies, such as creating, packaging or labeling “products that are appealing to youth” will carry fines and prison terms. Growing, importing, exporting, or selling marijuana without a federal license will remain serious federal offenses.

The federal minimum age to buy marijuana will be 18, but the provinces can set higher minimum ages. Adults can possess as much as 30 grams of pot in public and families are allowed to grow four marijuana plants (to a maximum height of one meter). Aggressive marketing will be discouraged, product information limited largely to brand name, ingredients, strain of marijuana, and the government may insist on plain packaging. Police would be allowed to administer a saliva test to motorists to screen for THC, the psychoactive ingredient in marijuana.

In the workplace, employees would not have the right to freely use marijuana and are still expected to show up sober and ready to work, an assessment in the Globe and Mail newspaper concluded. In the province of Ontario, specifically, restrictions on smoking tobacco in the workplace would apply equally to the smoking of marijuana.

Given Trudeau’s Liberal Party majority, and support from the left-leaning New Democratic Party, recreational pot legalization is expected to pass easily. Conservative Party members voiced opposition, asserting that legalization would only increase adolescent marijuana use, while doctors – who have long had misgivings about medical marijuana – expressed grave concerns about the impact on youth.

The Canadian Pediatric Society warns that legalization does not mean the drug is safe. The doctors hold that one in seven teenagers who start using cannabis develop cannabis-use disorder and, though the adult brain seems able to recover from chronic pot use in just a few weeks, teens who smoke pot frequently can do long-lasting damage to their brains. Concerns about danger to the adolescent brain prompted the Canadian Medical Association to urge the government to ban the sale of marijuana to people under 21 and to restrict the amount and potency of the drug available to those under 25.

Protecting youth, Health Minister Jane Philpott maintains, is “at the center” of the legalization measure, and the government promises, “a robust public education campaign to inform youth of the risks and harms of cannabis use.” Clearly, one is needed, for Canadian Youth Perceptions on Cannabis, a study released at the end of January by the nonprofit Canadian Centre on Substance Abuse found “Young people think marijuana is neither addictive nor harmful.”

Speaking in support of the marijuana measure, Blair maintains that legalization is not aimed at promoting use of the drug or to maximize tax revenues. “In every other jurisdiction that has gone down the road of legalization, they focused primarily on a commercial regulatory framework. In Canada, it’s a public-health framework.”

Commentary

Canada’s plan for legalization contains much that is attractive to those who believe—as we do—that the paramount issue is limiting adolescent marijuana use. Legalization in the United States has, as opponents point out, led to increased teen use of the drug. Advocates for the Canadian plan contend that what they propose should not raise the nation’s already sky-high rate of youthful use. We doubt that any measure sanctioning adult use can prevent that.

TRADING PLACES: POT OR PAINKILLERS?

Researchers are becoming interested in how certain marijuana components could be used in controlled settings to help curb the opioid crisis. While U.S. Attorney General Jeff Sessions has mocked the idea as “stupid,” recent studies suggest that weed may be a safe substitute for opioid painkillers as well as an aid to curbing opioid abuse. “Epidemics require a paradigm shift in thinking about all possible solutions,” Yasmina Hurd, a neuroscientist at Mount Sinai Hospital in New York, argued in Trends in Neuroscience, explaining the growing interest in pot for these purposes. “We have to be open to marijuana because there are components of the plant that seem to have therapeutic properties.”

At this point, however, studies suggest only correlations between medical marijuana use and reducing chronic pain and opioid addiction. Preclinical animal models have demonstrated that CBD, a non-psychoactive element in marijuana, reduces the rewarding properties of opioid drugs and withdrawal symptoms. A small pilot study by Dr. Hurd mirrored these conclusions, as did research at the University of Michigan and a RAND Corporation paper with researchers at University of California, Irvine that compared states with and without medical marijuana dispensaries.

While intriguing, these initial findings are largely observational and anecdotal. They do not support changing current clinical practice towards cannabis, as the lead author of the Michigan study, Keith Boehnke, has stated. For one thing, these studies were conducted with patients at medical dispensaries who are more inclined to endorse the benefits of medicinal marijuana. Still, it is worthwhile exploring pot as an alternative to dangerous prescription opioid painkillers or to reduce opioid addiction. Research must be pursued in long-term, large-scale clinical studies that focus solely on the CBD component and not THC, a powerful psychoactive element in marijuana.

THE STATES TAKE ACTION: VERMONT AND NEW HAMPSHIRE

These neighboring New England states are struggling to contain the opioid epidemic that has ravaged their communities. Drug overdose mortality rates in 2015 reached 16.7 per 100,000 inhabitants in Vermont, and 34.3 n New Hampshire - one of the nation’s highest, according to the Centers for Disease Control and Prevention.

Vermont

In 2014 Vermont’s then-governor Peter Shumlin sounded the alarm about his state’s intensifying opioid epidemic, declaring a “full-blown crisis” with a spiraling number of drug overdoses and persons seeking treatment. The state legislature responded with measures to expand the use of overdose reversal drugs; introduce prescription rationing (as of January 2017); promote treatment options in lieu of prosecution and incarceration; and develop the state’s “spoke-and-hub” treatment infrastructure of centralized and local care.

After leveling off for a few years, the number of Vermonters who died from drug overdoses spiked in 2016 to 104, up from 66 the year before, almost evenly split between heroin and fentanyl overdoses. The victims represented a cross section of the state’s population: blue collar and professional class, rural and urban, old and young, and roughly 30 percent were women, the Vermont website Seven Days reported. Vermont’s anti-opioid efforts have had some impact. Indeed, the overdose numbers could have been worse if not for the widespread distribution of the overdose reversal drug Narcan, and the opening of more treatment facilities and a reduction in waiting times.

New Hampshire

Despite a relatively small population of 1.4 million, more than double neighboring Vermont, New Hampshire is often called “ground zero” of the rural opioid epidemic. In 2015, the state reported 439 drug overdose deaths - the second highest per capita rate in the nation after West Virginia – and 478 deaths are estimated for 2016.

The state response has focused on expanding access to treatment (New Hampshire ranked second to last nationwide in access to treatment), addressing a shortage of trained staff in recovery programs, and increasing the number of doctors licensed to prescribe Suboxone, a drug that eases withdrawal symptoms. Other measures include a drug crisis hotline; the Safe Station program, where addicts can seek help and referrals at fire stations; and stricter prescription monitoring rules that went into effect at the start of 2017. More than 10,000 persons have received addiction treatment after gaining coverage through the Medicaid expansion under the Affordable Care Act.

Holly Cekala, executive director of Hope for New Hampshire, a recovery community nonprofit, says the state is making strides to confront the epidemic and has come a long way from the “treatment apocalypse” it faced when the crisis first unfolded. But considering the high number of overdoses and waiting times for residential treatment – averaging four to six weeks – “there’s still a lot of work to be done,” she told the Rosenthal Report.

Commentary

Vermont and New Hampshire are taking the right steps to control the opioid epidemic, putting in place programs that will help save lives and get addicts into effective treatment. In both states, there is a range of options including outpatient and residential treatment lasting up to 90 days, including medication-assisted treatment (MAT) – especially in Vermont. Hard-hit New Hampshire needs to increase the number of residential treatment places and add more recovery housing; raise Medicaid reimbursement payments to allow more lower-income patients to enter treatment; and provide more prison-based drug treatment programs. It’s a resolutely stubborn public health crisis that will take time and determination to overcome.

4th May 2017

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The Rosenthal Report - April 2017

Rosenthal Reports

CONFRONTING THE OPIOID EPIDEMIC

This month’s Rosenthal Report examines new efforts announced by New York City and the State of New Jersey to stem the escalating opioid crisis, as well as the impact of opioid rationing and monitoring programs. Both are urgently needed as the opioid death toll escalates: 52,401 Americans died from overdoses in 2015, including more than 20,000 from opioid pain relievers and nearly 13,000 from heroin or heroin synthetics.

It would be unfair to directly compare the two initiatives, since states (mostly with federal funds) provide, by far, the greatest amount of substance abuse service. Both, however, are responding to mounting numbers of overdose fatalities in different ways: New York City with a limited, narrowly focused approach and New Jersey with a broader and more comprehensive one. Reducing the number of fatalities however will not necessarily reduce the number of overdoses, because it is only by successfully addressing addiction itself can we curb the crisis.

New York City Mayor Bill de Blasio Announces Anti-Opioid Initiative

Faced with a surge of opioid overdose deaths, de Blasio outlined a new initiative to combat the crisis and pledged $38 million annually to reduce the number of opioid deaths by 35 percent over the next five years. An estimated 1,300 New Yorkers died of drug overdose in 2016—the highest number on record. More than 1,075 of those died from opioid pain pills or opiates like heroin and the powerful synthetic opioid fentanyl, which accounted for 90 percent of opiod drug deaths last year compared to fewer than 5 percent from fentanyl before 2015.

The Mayor’s plan, called HealingNYC, includes a reliable mix of prevention, outreach, professional training and supply reduction. To reduce overdose deaths, the city will distribute 100,000 naloxone kits to treatment centers, homeless shelters and pharmacies. And, for the first time, all 23,000 NYC Police Department patrol officers will carry the overdose reversal drug and be trained to use it.

Also on the agenda are public awareness campaigns; more mental health clinics in high-need schools with a disproportionate share of suspensions and mental health issues, which can be precursors to substance abuse. According to a City Hall statement, education programs for clinicians to reduce overprescribing are part of the initiative, as are doubling to 600 the number of inmates receiving methadone on Rikers Island, and the creation of police “Overdose Response Squads” that will target dealers in high-risk neighborhoods and “disrupt the supply of opioids before they come into the city,” according to a City Hall statement.

Another key element is providing medication-assisted treatment (MAT) for addiction to an additional 20,000 New Yorkers by 2022. Ten NYC hospital emergency departments will establish buprenorphine induction (the first phase of treatment to find the patient’s ideal daily dose of the drug) and what is called “care management” through the stabilization and maintenance phases.

A Health Department spokesperson told the Rosenthal Report that HealthyNYC intends to make “the full spectrum of evidence based drug treatment” available to New Yorkers, including rehab beds and counseling at overdose programs and outpatient clinics. Still, the Mayor’s initiative is intensely focused on “increasing the availability and use of buprenorphine,” the spokesperson said, noting that the drug is currently underutilized in the city’s drug programs.

First of a series: The States Take Action

NEW JERSEY
Entering his last year in office, two-term governor Chris Christie announced a comprehensive opioid emergency plan this past January. It establishes a broad framework for tackling the epidemic from a patchwork of programs already in place, including equipping emergency responders with overdose reversal drugs and training former drug users as counselors to drug addicts admitted to hospital emergency rooms.

Christie’s plan followed a grim year for drug deaths in the state: overdoses from heroin and other opiates, including the powerful synthetic opioid fentanyl, claimed the lives of 1,600 drug users in New Jersey—a 20 percent increase over the previous year’s total. The governor’s first step was to declare a public health emergency, which gives him additional resources to battle the epidemic, and launch a television ad—with himself as pitchman—urging viewers to use a new one-stop website and telephone hotline to learn about addiction resources.

The initiative includes substantive measures covering education and prevention, opioid prescription monitoring, and insurance coverage. In addition, there are regulations that limit physician prescriptions of opioids to a five-day supply instead of a 30-day one; rule changes that consider 18- and 19-year olds to be children to reduce waiting lists for treatment beds; proposed legislation that would require private insurers to pay for at least six months of drug treatment; and expanded education programs, starting in kindergarten, about avoiding opioid abuse.

Democratic lawmakers in the state generally embraced the plan, but it already faces resistance from a physicians lobbying group, the Medical Society, which said it would be “cruel” to patients to limit prescriptions as well as an “intrusion” on medical practice. Christie’s initiative got a reprieve when the GOP’s healthcare plan, which would have jeopardized Medicaid funding to the states and substance abuse programs, was withdrawn. And with Christie named to lead an anti-opioid drug commission within the White House’s new Office of American Innovation, his influence may also be felt at the federal level – and with the backing of President Trump.

COMMENTARY

All efforts to address the opioid crisis ravaging America’s urban and rural communities are to be applauded. Both the New York City and New Jersey initiatives include excellent ideas and effective policies, but the blueprint they offer is incomplete. The orientation (especially in New York) on curbing overdose deaths represents a short term, medication-based emergency response plan rather than a comprehensive long-term strategy that would lead patients to full recovery.

That approach would require more than Mayor de Blasio’s planned $38 million expenditure. By comparison, he has allocated $1.6 billion for the Vision Zero safe streets initiative to eliminate traffic injuries and deaths. “We have made a commitment to decisively confront the epidemic of traffic fatalities and injuries,” the Mayor has said. The same should hold true for substance abuse and drug addiction. What about a Vision Zero for the addiction epidemic? It’s time to think bigger and bolder about bringing this crisis under control.

A CLOSER LOOK: The Risks and Rewards of Opioid Rationing

In one form or another, rationing opioids is now a reality. Every state except Missouri has special prescription limitations, and the Center for Disease Control (CDC) has issued voluntary pain management guidelines backed by the surgeon general intended mainly for primary care physicians treating patients for non-cancer chronic pain.

The motivation for rationing and monitoring is clear: prescription painkillers can be a gateway to addiction and abuse. A paper published in the current Annals of Surgery, reported that three out of four recent heroin users say they were introduced to opioids by prescription medications. Unconsumed opioid pills remained in four out of five filled prescriptions, and one out of every five “opioid-naïve” surgical patients “continue to require opioids long after their surgical care is complete.”

A recent CDC study found that that risk of addiction for a representative sample of “opioid-naïve” cancer-free patients increased with each day of medication – starting with day three. Only six percent of the 1.3 million patients in the sample who were given a one-day supply were using opioids a year after their initial prescription. That number doubled to 12 percent for those given a six-day supply and to 24 percent if that first supply was for 12 days.

February’s Rosenthal Report told how ER doctors are cutting back on narcotic painkillers. Dentists are also heeding this advice. They prescribe about 8 percent of all opioid drugs—and more than 30 percent of those given to patients aged 10 to 19. Last year, the American Dental Association recommended that dentists consider over-the-counter pain relievers as “first-line therapy for acute pain management.”

Now, surgeons are testing painkiller rationing. A Washington Post story highlighted a study at Dartmouth-Hitchcock Medical Center in New Hampshire that limited opioid prescriptions to a specific number of pills for five of the most common outpatient surgical procedures (for example, five pills for a partial mastectomy, and ten for a lymph node biopsy.) In addition, patients were counseled in the use of non-narcotic, over the counter pain relievers such as ibuprofen to manage pain.

A follow-up survey confirmed the efficacy of rationing: the total number of pills fell to under 3,000 from more than 6,000 for the 224 patients in the study. Moreover, a smaller sample of 148 patients was found to have taken only about half of the pills that were prescribed. Although only one patient returned to the medical center for a refill prescription, others may have sought additional pain medication from their primary care physicians, who write close to half of all opioid prescriptions.

For those in favor of opioid rationing, the definitive factor in the explosive over-prescription of pain medication was the promotion of a high-potency, time-release opioid painkiller (OxyContin) in the late 1980s and early 1990s as well as the notion that addiction due to prescribed opioid pain management is rare. But, while promotion of that new painkiller did indeed play a key role, so did the long-time under-treatment of pain that preceded today’s concern for patient satisfaction.

The organization, Physicians for Responsible Opioid Prescribing (PROP), is a leader in the rationing campaign. It argues that while prescribed narcotics can lead to addiction, too much attention is given to how severely a patient’s chronic condition hurts. Reducing the intensity of pain, PROP maintains, should not be the goal of treatment for chronic pain. “Willingness to accept pain, and engagement in valued life activities despite pain, may reduce suffering and disability without necessarily reducing pain intensity,” the organization insists.

While PROP’s position enjoys support within the medical community, many doctors find the rationing campaign and “opioid phobia” troubling because opioids also clearly help some patients. A previous Rosenthal Report cited the example of Dr. Sean Mackey, head of Stanford University’s pain management program, who described a patient on an opioid regime for a severe foot injury who was able to continue working.

To be sure, physicians must carefully consider the risks and rewards. The monitoring programs have had a significant impact on prescribing practices, and have reduced “doctor shopping” – when patients seek out doctors who will prescribe more opioids. Nevertheless, the number of opioid deaths continues to rise; many patients are driven to illicit drugs; and although the rate of fatalities from the use of commonly prescribed opioid medications has flattened, the rate of death from heroin and heroin synthetics is increasing.

Equally important, critics say the CDC guidelines ignore the needs of the individual patient and lack compassion for their pain. Many patients feel like addicts or criminals when they require more painkillers after other medical interventions have failed. The tragedy is that doctors cannot agree on an approach to pain medication that recognizes both the need to control levels of opioid prescribing and the obligation to relieve patient pain.

4th April 2017

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The Rosenthal Report - April 2017

Rosenthal Reports

CONFRONTING THE OPIOID EPIDEMIC

This month’s Rosenthal Report examines new efforts announced by New York City and the State of New Jersey to stem the escalating opioid crisis, as well as the impact of opioid rationing and monitoring programs. Both are urgently needed as the opioid death toll escalates: 52,401 Americans died from overdoses in 2015, including more than 20,000 from opioid pain relievers and nearly 13,000 from heroin or heroin synthetics.

It would be unfair to directly compare the two initiatives, since states (mostly with federal funds) provide, by far, the greatest amount of substance abuse service. Both, however, are responding to mounting numbers of overdose fatalities in different ways: New York City with a limited, narrowly focused approach and New Jersey with a broader and more comprehensive one. Reducing the number of fatalities however will not necessarily reduce the number of overdoses, because it is only by successfully addressing addiction itself can we curb the crisis.

New York City Mayor Bill de Blasio Announces Anti-Opioid Initiative

Faced with a surge of opioid overdose deaths, de Blasio outlined a new initiative to combat the crisis and pledged $38 million annually to reduce the number of opioid deaths by 35 percent over the next five years. An estimated 1,300 New Yorkers died of drug overdose in 2016—the highest number on record. More than 1,075 of those died from opioid pain pills or opiates like heroin and the powerful synthetic opioid fentanyl, which accounted for 90 percent of opiod drug deaths last year compared to fewer than 5 percent from fentanyl before 2015.

The Mayor’s plan, called HealingNYC, includes a reliable mix of prevention, outreach, professional training and supply reduction. To reduce overdose deaths, the city will distribute 100,000 naloxone kits to treatment centers, homeless shelters and pharmacies. And, for the first time, all 23,000 NYC Police Department patrol officers will carry the overdose reversal drug and be trained to use it.

Also on the agenda are public awareness campaigns; more mental health clinics in high-need schools with a disproportionate share of suspensions and mental health issues, which can be precursors to substance abuse. According to a City Hall statement, education programs for clinicians to reduce overprescribing are part of the initiative, as are doubling to 600 the number of inmates receiving methadone on Rikers Island, and the creation of police “Overdose Response Squads” that will target dealers in high-risk neighborhoods and “disrupt the supply of opioids before they come into the city,” according to a City Hall statement.

Another key element is providing medication-assisted treatment (MAT) for addiction to an additional 20,000 New Yorkers by 2022. Ten NYC hospital emergency departments will establish buprenorphine induction (the first phase of treatment to find the patient’s ideal daily dose of the drug) and what is called “care management” through the stabilization and maintenance phases.

A Health Department spokesperson told the Rosenthal Report that HealthyNYC intends to make “the full spectrum of evidence based drug treatment” available to New Yorkers, including rehab beds and counseling at overdose programs and outpatient clinics. Still, the Mayor’s initiative is intensely focused on “increasing the availability and use of buprenorphine,” the spokesperson said, noting that the drug is currently underutilized in the city’s drug programs.

First of a series: The States Take Action

NEW JERSEY
Entering his last year in office, two-term governor Chris Christie announced a comprehensive opioid emergency plan this past January. It establishes a broad framework for tackling the epidemic from a patchwork of programs already in place, including equipping emergency responders with overdose reversal drugs and training former drug users as counselors to drug addicts admitted to hospital emergency rooms.

Christie’s plan followed a grim year for drug deaths in the state: overdoses from heroin and other opiates, including the powerful synthetic opioid fentanyl, claimed the lives of 1,600 drug users in New Jersey—a 20 percent increase over the previous year’s total. The governor’s first step was to declare a public health emergency, which gives him additional resources to battle the epidemic, and launch a television ad—with himself as pitchman—urging viewers to use a new one-stop website and telephone hotline to learn about addiction resources.

The initiative includes substantive measures covering education and prevention, opioid prescription monitoring, and insurance coverage. In addition, there are regulations that limit physician prescriptions of opioids to a five-day supply instead of a 30-day one; rule changes that consider 18- and 19-year olds to be children to reduce waiting lists for treatment beds; proposed legislation that would require private insurers to pay for at least six months of drug treatment; and expanded education programs, starting in kindergarten, about avoiding opioid abuse.

Democratic lawmakers in the state generally embraced the plan, but it already faces resistance from a physicians lobbying group, the Medical Society, which said it would be “cruel” to patients to limit prescriptions as well as an “intrusion” on medical practice. Christie’s initiative got a reprieve when the GOP’s healthcare plan, which would have jeopardized Medicaid funding to the states and substance abuse programs, was withdrawn. And with Christie named to lead an anti-opioid drug commission within the White House’s new Office of American Innovation, his influence may also be felt at the federal level – and with the backing of President Trump.

COMMENTARY

All efforts to address the opioid crisis ravaging America’s urban and rural communities are to be applauded. Both the New York City and New Jersey initiatives include excellent ideas and effective policies, but the blueprint they offer is incomplete. The orientation (especially in New York) on curbing overdose deaths represents a short term, medication-based emergency response plan rather than a comprehensive long-term strategy that would lead patients to full recovery.

That approach would require more than Mayor de Blasio’s planned $38 million expenditure. By comparison, he has allocated $1.6 billion for the Vision Zero safe streets initiative to eliminate traffic injuries and deaths. “We have made a commitment to decisively confront the epidemic of traffic fatalities and injuries,” the Mayor has said. The same should hold true for substance abuse and drug addiction. What about a Vision Zero for the addiction epidemic? It’s time to think bigger and bolder about bringing this crisis under control.

A CLOSER LOOK: The Risks and Rewards of Opioid Rationing

In one form or another, rationing opioids is now a reality. Every state except Missouri has special prescription limitations, and the Center for Disease Control (CDC) has issued voluntary pain management guidelines backed by the surgeon general intended mainly for primary care physicians treating patients for non-cancer chronic pain.

The motivation for rationing and monitoring is clear: prescription painkillers can be a gateway to addiction and abuse. A paper published in the current Annals of Surgery, reported that three out of four recent heroin users say they were introduced to opioids by prescription medications. Unconsumed opioid pills remained in four out of five filled prescriptions, and one out of every five “opioid-naïve” surgical patients “continue to require opioids long after their surgical care is complete.”

A recent CDC study found that that risk of addiction for a representative sample of “opioid-naïve” cancer-free patients increased with each day of medication – starting with day three. Only six percent of the 1.3 million patients in the sample who were given a one-day supply were using opioids a year after their initial prescription. That number doubled to 12 percent for those given a six-day supply and to 24 percent if that first supply was for 12 days.

February’s Rosenthal Report told how ER doctors are cutting back on narcotic painkillers. Dentists are also heeding this advice. They prescribe about 8 percent of all opioid drugs—and more than 30 percent of those given to patients aged 10 to 19. Last year, the American Dental Association recommended that dentists consider over-the-counter pain relievers as “first-line therapy for acute pain management.”

Now, surgeons are testing painkiller rationing. A Washington Post story highlighted a study at Dartmouth-Hitchcock Medical Center in New Hampshire that limited opioid prescriptions to a specific number of pills for five of the most common outpatient surgical procedures (for example, five pills for a partial mastectomy, and ten for a lymph node biopsy.) In addition, patients were counseled in the use of non-narcotic, over the counter pain relievers such as ibuprofen to manage pain.

A follow-up survey confirmed the efficacy of rationing: the total number of pills fell to under 3,000 from more than 6,000 for the 224 patients in the study. Moreover, a smaller sample of 148 patients was found to have taken only about half of the pills that were prescribed. Although only one patient returned to the medical center for a refill prescription, others may have sought additional pain medication from their primary care physicians, who write close to half of all opioid prescriptions.

For those in favor of opioid rationing, the definitive factor in the explosive over-prescription of pain medication was the promotion of a high-potency, time-release opioid painkiller (OxyContin) in the late 1980s and early 1990s as well as the notion that addiction due to prescribed opioid pain management is rare. But, while promotion of that new painkiller did indeed play a key role, so did the long-time under-treatment of pain that preceded today’s concern for patient satisfaction.

The organization, Physicians for Responsible Opioid Prescribing (PROP), is a leader in the rationing campaign. It argues that while prescribed narcotics can lead to addiction, too much attention is given to how severely a patient’s chronic condition hurts. Reducing the intensity of pain, PROP maintains, should not be the goal of treatment for chronic pain. “Willingness to accept pain, and engagement in valued life activities despite pain, may reduce suffering and disability without necessarily reducing pain intensity,” the organization insists.

While PROP’s position enjoys support within the medical community, many doctors find the rationing campaign and “opioid phobia” troubling because opioids also clearly help some patients. A previous Rosenthal Report cited the example of Dr. Sean Mackey, head of Stanford University’s pain management program, who described a patient on an opioid regime for a severe foot injury who was able to continue working.

To be sure, physicians must carefully consider the risks and rewards. The monitoring programs have had a significant impact on prescribing practices, and have reduced “doctor shopping” – when patients seek out doctors who will prescribe more opioids. Nevertheless, the number of opioid deaths continues to rise; many patients are driven to illicit drugs; and although the rate of fatalities from the use of commonly prescribed opioid medications has flattened, the rate of death from heroin and heroin synthetics is increasing.

Equally important, critics say the CDC guidelines ignore the needs of the individual patient and lack compassion for their pain. Many patients feel like addicts or criminals when they require more painkillers after other medical interventions have failed. The tragedy is that doctors cannot agree on an approach to pain medication that recognizes both the need to control levels of opioid prescribing and the obligation to relieve patient pain.

4th April 2017

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Tell the President:

Other

DON’T dump the Drug Czar

DO save the ONDCP

Drug overdose kills more than 52,000 Americans a year—more than cancer, more than auto accidents.
A cohesive national anti-addiction policy is essential.
But the Office of Drug Control Policy (ONDCP), the part of your White House that oversees
the nation’s anti-drug efforts, is on the hit list of the Budget Office, along with PBS, Americorps, and the National Endowments.
Eliminating ONDCP will save roughly $25 million for salaries, expenses, and policy research, and denyabout $350 million to critical drug control programs.
This is penny wisdom and pound folly at its worst.

-Mitchell S. Rosenthal, MD
President

1st March 2017

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Tell the President:

Other

DON’T dump the Drug Czar

DO save the ONDCP

Drug overdose kills more than 52,000 Americans a year—more than cancer, more than auto accidents.
A cohesive national anti-addiction policy is essential.
But the Office of Drug Control Policy (ONDCP), the part of your White House that oversees
the nation’s anti-drug efforts, is on the hit list of the Budget Office, along with PBS, Americorps, and the National Endowments.
Eliminating ONDCP will save roughly $25 million for salaries, expenses, and policy research, and denyabout $350 million to critical drug control programs.
This is penny wisdom and pound folly at its worst.

-Mitchell S. Rosenthal, MD
President

1st March 2017

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The Rosenthal Report - August 2016

Rosenthal Reports

What Congress Didn’t Do

Before it broke camp for its seven-week summer recess, Congress passed legislation to address the nation’s epidemic of opioid addiction. With more than 28,600 overdose deaths in 2014, an army of addicts uncovered or insufficiently covered by health care insurance, and a health system that lacks adequate capacity to meet today’s substance abuse treatment needs, President Obama had pressed Congress to provide $1.1 billion in new money, most of which would go to the states to support medically-assisted treatment (MAT) of opioid addiction.

After painful compromises had been worked out in both houses and the conference committee, the measure was passed and sent to the President. It authorizes the federal government to make grants to the states for addiction treatment and prevention programs, but fails to appropriate the funds for them. Although there was strong pressure—and clearly need—for an immediate appropriation, the summer recess began without it. House Republicans say they will appropriate $581 million (far less than the $1.1 billion requested by the administration) when they return to Washington, but there is no guarantee that this promise will survive the haggling over appropriations that comes as the government’s fiscal year winds down at the end of September.

What Congress and HHS Did Do

As part of the addiction treatment measure, Congress has made it possible for physician assistants and nurse practitioners to prescribe buprenorphine for patients in opioid treatment programs (OTPs). In a more significant move, the Department of Health and Human Services (HHS) increased the number of patients for whom authorized physicians (and now their surrogates) can prescribe buprenorphine step-down medications (such as Suboxone) from 100 patients to 275.

Threatened to be lost in the shuffle is the federal requirement that opioid treatment programs offering medically assisted treatment (MAT) provide “a range of services to reduce, eliminate, or prevent the use of illicit drugs, potential criminal activity and/or the spread of infectious disease.”

Bear in mind that the key word in medically assisted treatment is “assisted.” Medication itself is not treatment. SAMHSA (Substance Abuse and Mental Health Services Administration) defines medically assisted treatment as “the use of medications, in combination with counseling and behavioral therapies to provide a ‘whole patient approach’ to substance use disorders.” HHS requires physicians seeking to increase their patient limit to “attest” that they will “adhere to evidence-based treatment guidelines.”

It is not likely, however, that much in the way of behavioral healthcare services will be available at the “Suboxone clinics” now proliferating in states hit hard by the opioid abuse epidemic. And the prescription of buprenorphine’s step-down (and addictive) medications to an expanding list of patients troubles a good many health officials there. As the medical director of Tennessee’s Department of Mental Health and Substance Abuse Services warns, “I think the focus has been so much on expanding treatment and getting treatment out to people, that they really haven’t focused on some of the unintended consequences.”

High Risk Munchies

Pot is all too often good for a giggle, but news about marijuana edibles from the National Poison Data System is anything but humorous. Reporting on “single substance exposure calls” for marijuana cookies, candies and the like between January 2013 and December 2015, the poison service found 430 calls nationally with more than half from the two states that have legalized recreational marijuana use. There were 166 calls from Colorado and 96 from Washington, with the number of calls increasing over the course of the study. The age group found most at risk were children under five, who were the subjects of 109 calls. Lethargy, rapid heartbeat, and agitation were the most common symptoms. Three exposed patients (including a four-year-old) had to be intubated, half were hospital treated and released, and three admitted to a critical care unit. Our friends at NFIA (National Families in Action) and SAM (Smart Approaches to Marijuana) alerted us to the Poison Center’s report and also to news about Défoncé Chocolatier’s high end marijuana chocolates (see below).

High Test Bonbons

The high style, high powered inaugural bar of Défoncé chocolate comes in 18 pyramid-shaped detachable segments and 180 milligrams of THC. With concentrated cannabis extract alleged to spread evenly throughout the bar, each pyramid section should deliver a ten-milligram hit of THC, believed to be roughly equivalent to several good pipe puffs. Défoncé (it’s French for “stoned”) is the creation of a former production manager at Apple set on delivering a fashionable product with predictable high-making capacity. Available now in California dispensaries, the Défoncé bar comes in such flavors as coffee, vanilla bean, dark, mint, and hazelnut. The obvious question is how hard is it for consumers to stop munching after a pot-laden pyramid or two.

1st August 2016

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The Rosenthal Report - July 2016

Rosenthal Reports

Drug Abuse by Any Other Name

It made headlines when Michael Botticelli, the White House drug czar blamed “terms like abuser and addict” for discouraging people with drug use disorders from seeking treatment. The head of the Office of National Drug Control policy was hardly setting a trend. The words “abuse” and “abuser” no longer appear in publications and communications of the Substance Abuse and Mental Health Administration and “abuse” has been replaced by “substance use disorder” in psychiatry’s latest Diagnostic and Statistical Manual of Mental Disorders. Government and the treatment field in general seem bent on expunging language they see as contributing to the stigmatization of addiction, and they would rename the National Institute on Drug Abuse if this didn’t require action by Congress.

Stigma, it seems, has a bad name. It has—to make perhaps too fine a point—been stigmatized and unfairly so, for stigma has served for centuries as one of the most useful of social mechanisms. It is the most civil means of sanctioning behavior that threatens the community, violates community mores or norms, or is simply unattractive. This is not at all a bad thing when you consider the alternative. Without informal social controls communities turn to power to modify behavior they find sufficiently frightening, repugnant, or aberrant. We call the cops to curb the negative behaviors we cannot shame. We criminalize it, as we did with substance misuse.

Now that we are in the process of decriminalizing drug use it is no time to abandon stigma as well. If stigma is cool enough to use against smokers, why decide it’s too cruel to turn on heroin addicts? Shame works, argues psychiatrist Sally Satel in an article that answers positively the question “Can Shame Be Useful?” Although repeated drug use may indeed alter the brain, especially the regions that mediate self-control, “A vast literature,” she points out, “shows that addiction is an activity that can be altered by its foreseeable consequences.” As for the notion that drugs hold captive (or highjack) the drug user’s brain, see below.

Doubting the Disease Model

A slowly growing wave of dissent appears to be challenging the conviction put forth in the New England Journal of Medicine at the start of the year by Nora Volkow, the head of NIDA, and her co-authors. Their article celebrated increasing acceptance of addiction as “a chronic relapsing brain disease” and resulting neurobiological advances due to acceptance of the brain disease model.

In June, the neuroscientist Marc Lewis challenged the disease model in The Guardian. If addiction is a disease, he wrote, “We might wonder how the disease of addiction could be overcome as a result of willpower, changing perspective, changing environments, or emotional growth. There is evidence that each of these factors can be crucial in beating addiction, yet none of them is likely to work on cancer, pneumonia, diabetes, or malaria.” Further, Lewis reasons, “Once they recover, as most addicts eventually do, it is confusing and debilitating to be told they are chronically ill.”

Before the month ended, writer Maia Szalavitz put forth her own case in the Sunday Times that “addiction is neither a sin nor a progressive disease.” It is, she contends, a learning disorder. Addiction, she allows, “skews choice—but doesn’t completely eliminate free will.”

Moreover, belief in the disease model is nowhere near as widespread as the Volkow article suggests. A recent survey of public perceptions of drugs, drug use, and addiction, commissioned by the Rosenthal Center and conducted by the Schoen Consulting group, found three out of four Americans reject the notion that addiction is incurable. As for the hard held conviction of most brain scientists that addicts are powerless before their addiction, only 16 percent of the population strongly agrees and 44 percent flatly reject it.

Making Overdoses Safer—Not Necessarily Fewer

It could hardly have been any cuter. Adorable nine-year-old Audrey Stepp was practicing injecting her stuffed lamb with naloxone. The scene was shown on an ABC “20/20” broadcast interview with Audrey and her mother and was picked up by other evening news broadcasts. It wasn’t make-believe. Audrey was practicing how to inject her older brother Sammy who has struggled with heroin addiction for the past six years.

Naloxone is now available, without a prescription, (in nasal spray and hand-held automatic injector) at most pharmacies across the country. NIDA has just created a web section providing “how to” information about the overdose reversal medication for families like Audrey’s. According to the Institute, Naloxone is now “a front line tool used by first responders in preventing opioid overdose deaths”—a laudable goal, when overdose killed some 18 thousand users of opioid painkillers and more than 10 thousand heroin users in 2014.

But what then? What follows? As U.S. News & World Report reported on June 6th, a recent study of prescriptions filled for overdose patients during the thirty days following their hospital release found only 16.7 percent filled prescriptions for addiction treatment medication, and 22.4 percent got opioid painkillers.

While we clearly need to reduce the horrendous incidence of opioid overdose deaths, let’s not mistake a decline in fatalities as a victory over our society’s epidemic of drug misuse.

1st July 2016

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